A Patient Care Summary is a straightforward way to summarize and document a medical visit. It starts with capturing what the patient reports about their symptoms and concerns. Next, it includes the doctor’s observations, such as vital signs and exam results. The summary then outlines the doctor’s assessment or diagnosis based on this information. Finally, it details the next steps for treatment, any follow-up appointments, and advice given to the patient. This approach ensures clear communication and helps the patient connect the dots inside of their care.