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In this tutorial, you'll learn to effectively obtain and document patient information through restatement, reflection, and clarification. Start the interaction by greeting the patient pleasantly, 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 selecting a quiet and private space for the interview. Clearly explain the need for accurate information. Utilize therapeutic communication techniques to complete the history form, gathering details such as the patient's full name (including middle initial), address (including apartment number and zip code), marital status, gender, age, date of birth, telephone numbers (home, cell, and work), insurance information, and employer details, if applicable.
