Which document contains a patient’s medical history and care directives?

The medical record is the document that contains a comprehensive overview of a patient's medical history, including past illnesses, treatments, medications, allergies, and diagnostic assessments. It is an essential tool for healthcare providers, as it allows them to deliver informed and effective care. Furthermore, the medical record includes care directives, which specify what actions should be taken regarding a patient's treatment preferences, especially in situations where they may not be able to communicate their wishes. This document is vital for maintaining continuity of care among healthcare providers and ensuring that the patient’s preferences are respected.

In contrast, the patient intake form is primarily used to collect initial information about the patient at the point of care. The care plan, while it outlines the strategy for managing a patient's health and treatment goals, is derived from the information documented in the medical record. The discharge summary provides a summary of the patient's hospitalization and instructions for follow-up care but does not contain a complete medical history. Thus, the medical record stands out as the document that encapsulates all relevant details about a patient's medical background and care directives.