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In this tutorial, you'll learn how to effectively gather and document patient information using techniques like restatement, reflection, and clarification. Begin by greeting the patient warmly, introducing yourself, and explaining your role. For example, say, "Hi Mr. Dixon, I'm Laura, and I'm going to update your medical record today." To ensure confidentiality, conduct the interview in a quiet, private area. Clearly communicate the purpose of the information gathering, and utilize therapeutic communication techniques as you complete the history form. Accurately record details such as the patient's full name, address, marital status, gender, age, date of birth, telephone numbers, insurance information, and employer contact details, checking existing electronic records for accuracy.
