I think the electronic health record (EHR) made some promises that it couldn't keep.

It's not really anyone's fault. Really, the EHR, and medical record as we know it, was a huge upgrade. Dr. Abraham Verghese wrote about it in the New York Times:

"How we salivated at the idea of searchable records, of being able to graph fever trends, or white blood counts, or share records at a keystroke with another institution — “interoperability”! — and trash the fax machine." — Dr. Abraham Verghese  

And while absolutely zero clinicians miss the fax machine, medical record documentation still has a long way to go.

But with the advent of clinical documentation improvement and emerging AI, I think healthcare is finally following through on that promise.

Let's dig into the somewhat messy state of electronic documentation, and see what the future holds.

What is clinical documentation? 

Clinical documentation makes up detailed records of a patient’s medical history and health information— including healthcare data like diagnosis codes and clinical information.

Now that we understand the technical definition, let's take a walk through time.

Until the 20th century, medical records were like "parley" in the Pirates of the Caribbean: more like guidelines than anything.

Basically, there wasn't a form of structured documentation that doctors could rely on. Notes were more about jogging your memory than about structured data recording.

But all of that evolved with Larry Weed's introduction of "the problem list," which later turned into the SOAP note format that we all know and love (loathe?) today.

Now, clinical documentation comes with a network of information— all housed in our good friend the electronic health record.

Medical record documentation: Types of notes

Different notes solve different problems.

The type of note you use is completely based on your specialty, practice, and circumstance.

Here are the most popular note formats for gathering patient information.

• Subjective, Objective, Assessment, Plan (SOAP) notes: A standard format for progress notes that tracks a patient’s treatment and progress over time through subjective information, objective findings, and records of diagnosis and treatment. 
• Admission and discharge summaries: This documentation method captures why patients are admitted to a hospital and their initial diagnosis and treatment plan, along with their final diagnosis, treatments, and follow-up instructions after discharge. 
• Medical reports: Detailed reports of different medical examinations and procedures, including those for a patient’s history and physical assessments, surgeries, consultations, and laboratory tests. 
• Treatment plans: A document that outlines a patient’s individualized care plan, goals, and planned interventions. 
• Transfer and handoff notes: A summary of a patient’s status and treatment needs during a patient’s transfer from one healthcare facility to another. 

Why is clinical documentation important? 

Larry Weed said it best:  

"We’re really not taking care of records; we’re taking care of people. . . . This record cannot be separated from the caring of that patient. . . . This is the practice of medicine.” — Dr. Larry Weed, Founder of SOAP Notes

Structured documentation matters because it supports patient outcomes, opens up care pathways, and captures the health information that matters most.

Here are some other ways that high-quality clinical documentation actually helps clinicians:

• Make informed decisions about patient care: Narrative documentation gives you a holistic view of a patient’s current status, treatment plans, and medical history, so healthcare providers can assess a patient’s condition and recommend future care effectively. It also facilitates better communication and transparency among healthcare team members, which is crucial for coordinated action and decision-making.
• Maintain accurate records for billing and reimbursement: Healthcare organizations need detailed records on the medical services provided to patients so insurance providers can approve payments smoothly. Inaccurate or missing records increase the risk of insurance claims being denied, which slows down reimbursements to healthcare facilities. Poor documentation could also hinder patient access to necessary services by preventing insurers from getting the justification they need to reimburse healthcare providers for necessary treatments or procedures.
• Keep legal records of important information: Like any formal documentation, it becomes a pivotal asset to navigate legal disputes appropriately. In healthcare, clinical documentation is crucial to help healthcare providers protect themselves against legal issues like malpractice claims, consent disputes, fraud investigations, confidentiality breaches, and more. Given the complexities and overall high-risk nature of patient care, clinical documentation keeps healthcare providers accountable so they can operate under a standard of quality that limits errors and violations. 
• Ensure regulatory compliance: Healthcare organizations in the US must comply with regulations like the  Health Insurance Portability and Accountability Act (HIPAA), Occupational Safety and Health Administration (OSHA) regulations, and many others. It’s one of the more heavily regulated industries in the country, with strict standards covering everything from information technology to patient rights, billing, and more. Clinical documentation is evidence that a healthcare provider has complied with these guidelines, giving regulators a clear trail of how different processes and procedures are handled within the organization. 
• Improving patient outcomes and care quality: Clinical documentation is an organization-wide initiative that keeps healthcare providers accountable for managing day-to-day administrative processes, meeting care quality standards, and protecting patients every step. You can’t improve processes and policies if they aren’t standardized and communicated across a healthcare team. With clinical documentation, clinicians have a single source of truth they can use to avoid mistakes, improve decision-making efficiency, and identify growth opportunities. 

But this only matters if the notes are clear and consistent—which is easier said than done.

Clinical documentation management and clinical documentation improvement

I'm going to throw some acronyms at you: CDM and CDI. While they're just a letter off, each supports the documentation process in its own way.

Clinical documentation management

Clinical documentation management (CDM) is the overall process of handling clinical documentation throughout its lifecycle.

These might include protocols like:

• Setting up suitable access controls to protect patient information
• Conducting regular audit checks
• Interoperability with EHR systems

💡 Think of CDM as the system that governs documentation processes to ensure smooth operations and regulatory compliance.

Clinical documentation improvement  

Clinical documentation improvement (CDI) programs focus on enhancing the quality, clarity, and specificity of medical records to accurately reflect patient care.

In a best case scenario, this involves a collaboration with CDI specialists to maintain documentation quality.

💡 Think of CDI as an ongoing process that optimizes documentation for accuracy, financial integrity, and patient care quality.

Clinical documentation management vs. clinical documentation improvement

Here are the key differences between the CDM and CDM toolkit.

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The future of medical record documentation

We've come a long way from handwritten notes, but clerical note-taking is its own challenge.

Between fragmented workflows, excessive administrative burden, and documentation requirements that often feel more about billing than patient care, it’s clear that we haven’t fully realized the promise of structured documentation. But we’re getting there.

Electronic documentation: future trends

Clinical notes have hit another inflection point.

Now, more than ever, we understand the impact of structured documentation.

But a recent study found that every extra hour spent working electronic documentation in the EHR led to a two percent increase in the odds of burnout. 

I can't say I'm loving those odds.

So: with the what, who, and why figured out, it's time to focus on how to get these notes done.

Here are the future trends in structured documentation.

AI in clinical documentation

Okay, just one more acronym to go. Along with CDM and CDI, advancements in ambient clinical intelligence (ACI) are letting AI handle the admin work brought on by the EHR.

Ambient dictation tools and AI scribes are designed to listen, transcribe, and write  structured notes.

The goal here is to take notes off of your plate while:

• Keeping clinical documentation integrity
• Maintaining note quality
• Capturing health information and patient outcomes

These might just be one step in the right direction, but it beckons in a future that focuses on the people in person-centric care.

By improving interoperability across EHR systems, clinicians will get better access to comprehensive health information, have stronger coordination across clinical care, and most importantly: no more pajama time.

Conclusion

The evolution of our documentation tells a story of progress and promise.

From unstructured, handwritten notes to the complex systems of today, each step has aimed to improve how we capture and use patient information.

With clinical documentation improvement programs and AI tools, healthcare is finally delivering on the EHR’s original promise. We’re moving closer to a stronger, more reliable medical record.

The journey isn't over, but the path ahead is promising. By continuing to prioritize technology that works for clinicians—and not the other way around—we can create a future where medical records are no longer a barrier, but a foundation for delivering exceptional care.

Freed is the most clinician-focused company in the world. Try our AI scribe for free today.