DOCUMENTATION
The most tangible outcome from a provider visit is often the "note" that emerges from an encounter with a clinician summarizing the findings and assessments of that visit in an office or inpatient setting. This note is used as a record for legal purposes to describe the care provided and as a communication tool to other providers. The note can further serve as justification for the charges attendant to that encounter; insurers often ask for copies of this documentation as part of auditing to ensure that the services were in fact rendered.