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In this tutorial, you will learn how to effectively gather and document patient information using techniques like restatement, reflection, and clarification. Begin by greeting the patient warmly, introducing yourself, and explaining your role. For instance, say, "Hi Mr. Dixon, I'm Laura, and I'll be updating your medical record today." Ensure confidentiality by choosing a private area for the interview and clarifying the purpose of collecting information. Use therapeutic communication to complete the history form accurately, capturing essential details such as the patient's full name, address (including apartment number and zip code), marital status, gender, age, date of birth, contact numbers, insurance information, and employer's details. Verify existing information in the electronic record when possible.
