What type of professional document might include a patient’s history, assessment, and treatment plan?

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The correct choice is a SOAP note, which stands for Subjective, Objective, Assessment, and Plan. This format is widely used in medical practice to systematically document a patient's medical history, current health status, and proposed treatment strategies in a clear and organized manner.

The 'Subjective' section encompasses the patient's reported symptoms and experiences, while the 'Objective' section includes the clinician's observations and any measurable data such as vital signs. The 'Assessment' portion synthesizes the subjective and objective information to identify the patient’s condition, and the 'Plan' outlines the steps for treatment and follow-up, including any medications prescribed, tests ordered, or referrals made.

In contrast, a patient referral typically only includes information necessary for transferring the patient to another provider, while a discharge summary provides a comprehensive overview of the patient’s hospital stay, summarizing their treatment and condition upon leaving the facility. A medical billing statement, on the other hand, focuses on the financial transaction related to the patient's care, listing services rendered and their associated costs, but does not include clinical information regarding the patient's medical history or treatment plans.

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