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In this tutorial, you'll learn how to effectively gather and document patient information using techniques such as restatement, reflection, and clarification. Begin by greeting the patient warmly, introducing yourself, and explaining your role to establish comfort. It’s important to ensure confidentiality by conducting the interview in a quiet, private space. Clearly communicate the purpose of updating the medical record to the patient. Utilize therapeutic communication techniques to complete the history form, which includes recording the patient’s full name, address, marital status, gender, age, date of birth, telephone numbers, and insurance information. Additionally, document the employer's details if applicable, ensuring all information in the electronic record is accurate.
