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In this tutorial, you'll learn how to effectively obtain and document patient information using techniques such as restatement, reflection, and clarification. Begin by greeting the patient warmly, introducing yourself, and explaining your role. Choose a quiet, private area for the interview to ensure confidentiality. Explain the purpose of updating the medical records and utilize therapeutic communication to complete the history form. Collect essential patient details, including full name (with middle initial), address (including apartment number and zip code), marital status, gender, age, date of birth, telephone numbers (home, cell, work), and insurance information. Additionally, gather the employer's name, address, and contact number if applicable, checking for any pre-entered information in the electronic record.
