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In this procedure, you'll learn to use techniques such as restatement, reflection, and clarification to effectively gather and document patient information. Begin by greeting the patient warmly and introducing yourself, outlining your role in updating their medical record. Ensure confidentiality and minimize interruptions by choosing a quiet, private area for the interview. Explain the purpose of the information gathering, and complete the history form using therapeutic communication. Document the patient's full name (including middle initial), address (including apartment number and zip code), marital status, gender, age, date of birth, home, cell, and work phone numbers, as well as insurance details and the employer's contact information, verifying any existing data in the electronic record.
