In a medical record, what part typically contains a summary of a patient's conditions?

The section known as "Assessment and plan" in a medical record is specifically designed to provide a concise summary of a patient's conditions, as well as the healthcare provider's evaluation and proposed interventions. This part synthesizes information collected from the patient history and clinical notes to clearly outline the patient's current health status, diagnosis, and the next steps in their care plan. It effectively communicates the clinician's thought process and serves as a guide for ongoing treatment, making it essential for continuity of care.

On the other hand, the patient history primarily delves into the patient's background, including their medical history, family history, and other relevant factors, but does not summarize the current conditions. Clinical notes provide details about encounters with the patient, documenting observations and findings but may not distill this information into a summary of conditions. The order section contains requests for tests, medications, and treatments rather than a summary of the patient's health status.