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In this procedure, you will learn to use restatement, reflection, and clarification to gather patient information and accurately document care. Begin by greeting the patient pleasantly, identifying him, and introducing yourself. Explain your role, for instance, "Hi Mr. Dixon, I'm Laura, and I'm updating your medical record today." To maintain confidentiality, choose a quiet, private area for the interview. Explain the purpose of gathering information and complete the history form using therapeutic communication techniques. Record the patient's full name (including middle initial), address (including apartment number and zip code), marital status, gender, age, date of birth, telephone numbers, insurance information, and employer details, ensuring all entered data in the electronic record is verified.
