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In this tutorial, you'll learn to utilize restatement, reflection, and clarification techniques to gather and accurately document patient information while ensuring their comfort. Begin by greeting the patient warmly, introducing yourself, and explaining your role, for example, “Hi Mr. Dixon, I'm Laura, and I will be updating your medical record today.” Select a quiet, private space for the interview, and clarify the purpose of gathering information, emphasizing the importance of accurate records. Use therapeutic communication to complete the history form, collecting vital information such as the patient’s full name, address, marital status, gender, age, date of birth, phone numbers, insurance details, and employer information, while referring to existing electronic records when necessary.
