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In this tutorial, you will learn techniques for effectively gathering and documenting patient information using restatement, reflection, and clarification. Start by greeting the patient warmly, identifying yourself, and explaining your role. For example, say, "Hi Mr. Dixon, I'm Laura, and I will be updating your medical record today." Ensure confidentiality by conducting the interview in a quiet, private area. Explain the purpose of the information gathering. Complete the history form using therapeutic communication techniques. Record essential details such as the patient's full name, address, marital status, gender, age, date of birth, and contact numbers. Also, obtain insurance information and employer details, if applicable, before verifying any existing information in the electronic record.
