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In this procedure, you'll learn to obtain and document patient information using restatement, reflection, and clarification techniques. Start by greeting the patient pleasantly and introducing yourself, explaining your role. For confidentiality, conduct the interview in a quiet, private area. Inform the patient of the need for accurate information to update their medical records. Utilize therapeutic communication to guide the patient in completing the history form. Document essential details such as full name (including middle initial), address (with apartment number and zip code), marital status, gender, age, date of birth, telephone numbers (home, cell, and work), insurance information, and employer’s contact details, ensuring all information is accurate and any previously entered data is verified.
