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In this procedure, restatement, reflection, and clarification are used to obtain and document patient information accurately. The key points are greeting the patient, introducing yourself, explaining your role, choosing a quiet area for the interview, updating medical records for accuracy, and using communication techniques to complete the history form. Information to be recorded includes the patient's full name, address, marital status, gender, age, and telephone numbers. Additionally, insurance information and the employer's details should be collected if not already in the electronic record.
