What document outlines a patient’s treatment plan?

The care plan or treatment summary is the document that outlines a patient's treatment plan. It provides detailed information about the patient's diagnosis, the goals for treatment, the specific strategies or interventions to be employed, and the timeline for achieving those goals. This document is crucial for guiding the healthcare team in delivering consistent and effective care, as well as for communicating the plan to the patient and any other healthcare providers involved in the patient's care.

In contrast, the patient history document primarily captures the patient's medical background, including past illnesses, surgeries, medications, and family history, which inform the treatment plan but do not outline it. The diagnosis report confirms the specific medical condition but does not include a comprehensive treatment plan. A referral letter is used to refer a patient to a specialist and may include some treatment information but is not designed to outline a full treatment plan like a care plan or treatment summary does.