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In this tutorial, you'll learn to effectively use restatement, reflection, and clarification to gather patient information and accurately document care. Begin by greeting the patient warmly and introducing yourself, explaining your role. For example, say, "Hi Mr. Dixon, I'm Laura, and I'll be updating your medical record today." To ensure confidentiality, conduct the interview in a quiet, private area. Clearly explain the purpose of the information gathering. Complete the history form using therapeutic communication techniques, recording details such as the patient's full name, address, marital status, gender, age, date of birth, phone numbers, insurance information, and employer details. If information is already in the electronic record, verify its accuracy.
