Which document is used to record data about office procedures and services provided to patients?

The encounter form is specifically designed to capture detailed information about the services and procedures provided to a patient during an office visit. This document serves as a critical tool for healthcare providers, as it includes codes for diagnoses, treatments, and procedures performed, facilitating accurate and efficient medical billing and record-keeping.

The encounter form often lists various services with corresponding codes, which allows healthcare providers to document the care provided succinctly while also supporting billing processes. It enhances communication between clinical and administrative staff by summarizing key patient information in a standardized format, ultimately increasing the accuracy of claims sent to insurance companies.

The other documents mentioned serve different purposes. The patient history form primarily gathers information about the patient's medical history and current issues, which is not focused on the specific services rendered during a visit. The billing statement provides a summary of charges and payments for services rendered but does not detail the procedures performed. The referral letter is used when a patient is referred to another healthcare provider, outlining the reasons for the referral and relevant medical information but does not serve the purpose of documenting in-office procedures and services.