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In this tutorial, you'll learn to effectively use restatement, reflection, and clarification to gather patient information and document care accurately. Start by greeting the patient warmly, introducing 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 choosing a quiet, private area for the interview. Explain the necessity of the information being gathered. Utilize therapeutic communication techniques to complete the history form, recording the patient's full name, address (including apartment number and zip code), marital status, gender, age, date of birth, and telephone numbers. Additionally, collect insurance information and the employer's contact details. Be mindful of any pre-existing entries in the electronic record.
