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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, identifying and introducing yourself, and explaining your role, such as, "Hi Mr. Dixon, I'm Laura, and I'll be updating your medical record." Ensure confidentiality by selecting a quiet, private area for the interview. Clearly explain the necessity of collecting information and assist the patient in completing the history form. Record details such as the patient's full name, address (including apartment and zip code), marital status, gender, age, date of birth, and telephone numbers. Also, obtain insurance information and the employer's contact details. If any data is already in the electronic record, verify its accuracy.
