What is the term for the documentation created during a patient’s office visit?

The documentation created during a patient’s office visit is referred to as a progress note. This type of note serves to capture various aspects of the patient encounter, including the patient's current condition, the purpose of the visit, examinations performed, findings, assessments, and plans for ongoing care. Each progress note builds upon previous entries, providing a continual record of the patient’s health and treatment over time.

Progress notes are essential for maintaining accurate and detailed records that support clinical decision-making, communication among healthcare providers, and compliance with legal and regulatory standards. They document the evolution of a patient's condition and the healthcare team’s interventions, ultimately enhancing patient care continuity.

While other terms might refer to various types of documentation, such as summaries or reports, they may not specifically encompass the detailed and ongoing nature of the information recorded during each visit. Therefore, the term "progress note" accurately describes the focused and specific documentation produced during an office visit, making it the correct choice for this question.