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In this tutorial, you will learn to effectively gather and document patient information using restatement, reflection, and clarification techniques. Start by greeting the patient warmly, identifying yourself, and explaining your role. For example, say, "Hi Mr. Dixon, I'm Laura, and I'm updating your medical record today." Ensure confidentiality by selecting a quiet, private area for the interview. Explain the necessity of collecting the information. Utilize therapeutic communication to complete the history form, documenting the patient’s full name, address, marital status, gender, age, date of birth, telephone numbers, insurance details, and employer contact information. If some data is already in the electronic record, verify it for accuracy.
