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In this tutorial, you'll learn how to use restatement, reflection, and clarification to gather patient information and document care accurately. Begin by greeting the patient warmly, identifying and introducing 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 choosing a quiet, private area for the interview. Explain the purpose of collecting information and complete the history form using therapeutic communication techniques. Record the patient's full name (including middle initial), address, marital status, gender, age, date of birth, telephone numbers (home, cell, and work), insurance details, and the employer's name and contact information. If any data is already in the electronic record, verify its accuracy.
