How to Write Clinical Notes Faster—5 Easy Steps

Clinical notes are the building blocks of any patient's clinical record. With a good note, we can easily monitor a patient's progress and outline a plan of care.

But clinical documentation is just one aspect of the job—one that you'd probably like to finish by the end of your work day.

We've scoured forums and our personal network to find expert insights on how to:

• Quickly (and accurately) write clinical notes;
• Avoid note bloat and prioritize important patient data;
• Ensure compliance in your medical records.

Let's get started.

3 clinical note challenges & how to overcome them

In order to identify the right solutions, let's first dig into our biggest pain points.

Here are the chief complaints we've seen about writing clinical documentation, and how to solve them.

1. Finding time to write clinical notes

Sixty-four percent of healthcare professionals (that’s two-thirds!) feel overworked juggling too many responsibilities during shifts.

Handling clinical notes only adds up to the many administrative tasks that make up your day.

With such a busy schedule, finding time to write detailed patient notes often means bringing work home (for some good old-fashioned pajama time).

Our goal is to find a way for healthcare providers to shut down their laptop after business hours.

💡 Clinical note solutions

If we can make the note-taking process take only 5-10 minutes, we can schedule short intervals throughout the day.

Here are some tips on how to write notes faster.

1. Use an AI Scribe— Tools like Freed will capture, transcribe, and write SOAP notes that you can easily copy/paste into your EHR.

“Goodbye to the avalanche of charts. I now leave at 5pm with all tasks done. Freed is a game changer. You can be up and running in minutes.”
–
Dr. Maryam Zarei, MD Allergy, Asthma, and Immunology, California

2. Use a cheatsheet—Write up a list of reported symptoms, explored causes, and identified symptoms that you can easily plug and play in your next visit.

Here's an example of a therapy note cheat sheet created by an LMSW.

3. Lean into shorthand and text shortcuts— Cut back on your words as much as possible by familiarizing yourself with abbreviations

“I make use of shorthand and common medical abbreviations. These cutbacks on words not only quicken the process of documentation but also ensure clarity in the notes.”
—
Dr. Sam Singh; Winit Clinic

You can take this a step further by leveraging technology. One clinician on reddit uses TextBlaze to auto-fill common terms and sentences into their note.

2. Avoiding note bloat

The "perfect" clinical note is concise, with just the right amount of detail.

It can be tough writing a comprehensive clinical note that's also clear and easy to read.

On top of that, different patients and situations require different levels of detail. For example, a past disease is only relevant in certain contexts— and that'll vary from case to case.

So, besides finding time to write your notes, you also need to be able to quickly sift through the information and filter out the most important points.

💡 Clinical note solutions

Here are some practical ways to put only the most necessary information in your medical notes.

1.  Take notes as soon as you can— If possible, schedule 10-15 minutes in between patient visits so that you can take notes ASAP. Now that you have tips on how to write notes faster, this next step helps you ensure accuracy and record retention.  

“I try to document as close to the encounter as I can. That keeps the information fresh in my mind, so I miss fewer critical details and ensure that the information I put down is timely and accurate.”
—
Dr. Sham Singh, Winit Clinic

2. Find a format and stick to it— Whether you're opting for a traditional SOAP note or DAP structure, a standard template will help you organize your thoughts around the patient data you need.

2. Try a medical dictation or speech recognition tool—Take advantage of medical transcription AI to capture your conversations and observations in real time.

“To be able to dictate my notes and, further, have them typed out really enables me to take much more detailed observations at a speed so much faster than I could type. This helps me to record information in a much more natural flow since I can talk as I think.”
—
Dr. Sham Singh, Winit Clinic

3. Privacy concerns

Any data breach, whether accidental or not, can have serious consequences for both patients and healthcare providers.

To avoid it, you need to keep your notes compliant with basic legal considerations, privacy laws, and regulatory bodies (like HIPAA) in the U.S.

Of course, you don’t have to be an expert in information security or privacy laws.

Your organization should have clear policies in place for how to handle and store notes, and all you need is to stick to them. The tricky part is that with heavy workloads and tight schedules, even following established processes can be a challenge.

💡Clinical note solutions

1. Check your software for legal requirements— Ensure that all of your tools (including your medical note-taker or EHR) are HIPAA compliant and following industry best practices. This should be written in plain terms on any website.

‎2. Follow up with your clinic's legal requirements— Don't be afraid to check in with administrative team members in your healthcare organization if you're concerned about a process or tool. You and your patient's safety are worth it!

The benefits of streamlined clinical documentation

Excellent clinical documentation does more than reduce headaches—it can make you happier (and healthier!) at your job and even improve patient outcomes.

Here are the biggest benefits of optimized clinical notes.

Happier clinicians

Seventy-seven percent of healthcare workers find themselves staying late at work because of too much documentation.

Imagine a weekend with 0 notes left. It might be closer than you think.

While we'll never eliminate the need for medical notes and data management in healthcare, you can definitely make the process more efficient and free up more of your time.  

Consistent patient records

Once you master the balance between detail and structure, you'll find that documenting your clinical notes becomes more consistent and repeatable.

You'll spend less time writing them and less time searching through them when patients come back.

Consistent notes aren’t just a time-saver; they’re also easier to handle. Well-organized records streamline the process, making it simpler to read, update, and maintain them.

Improved care coordination

Think about how helpful it is when notes from another doctor are clear and easy to understand.

It saves you time and effort since you don’t have to dig through them or ask for clarifications. 

The same goes for when your notes are passed on to other doctors—they’ll appreciate it if your documentation is straightforward and organized, and it’ll save you from having to explain everything again.

With a standard process for note-taking, you can turn this from a rare happy occurrence into the norm.

Higher-quality patient care

Seven in ten respondents feel that the time spent on paperwork takes away from the time they could spend with patients. When documentation becomes a full-time job, it affects the quality of care you can provide.

By improving the note-taking process, you can free up more time to focus on what really matters. 

More accurate diagnoses

Good notes mean you’re less likely to miss symptoms or misinterpret patient information—especially when diagnosing requires multiple exams and consultations. 

When exam results come in, you’ll need to refer back to your clinical notes to create an effective treatment plan. Clear and accurate notes will help you make the right decisions and reduce the risk of errors in patient care.

Better legal protection

Detailed, accurate notes are a solid security asset for you and your organization. They give you a clear record of patient care, making it easier to handle any legal complications that come up. 

Keep your notes organized, and you’ll have reliable documentation to support your decisions and keep your practice on steady ground.

How to write clinical notes faster— a step-by-step guide

Writing clinical notes doesn’t have to be a headache. With these tips and tricks, you can create notes in 5-10 minutes.

Follow this simple step-by-step guide to create a better note-taking process and start reaping the benefits we’ve just talked about.

1. Choose a framework or template

First, you need to decide on a structure for your notes that you’ll use consistently.

Here are the most common templates used by healthcare providers worldwide.

• SOAP notes.
• DAP notes.
• BIRP notes.

SOAP notes

SOAP (Subjective, Objective, Assessment, Plan) notes are a classic choice that works well for most clinical settings.

It includes the four key components:

• The patient’s report (Subjective);
• Your observations (Objective);
• Your evaluation (Assessment);
• The treatment plan (Plan). 

This is a comprehensive clinical note type that lets you easily monitor a patient's progress and plan of care.

 “I find that keeping the SOAP format-Subjective, Objective, Assessment, and Plan-keeps my notes organized and concise for other healthcare providers to more quickly comprehend the status and plan regarding the patient.”
—
Dr. Sham Singh, Winit Clinic

DAP notes

DAP notes (Data, Assessment, Plan) offer a more straightforward approach.

Unlike SOAP, which separates subjective and objective information, DAP notes combine both into a single section labeled "Data."

This patient data section provides a detailed description of the patient's symptoms and other relevant information.

BIRP notes

BIRP notes (Behavior, Intervention, Response, Plan) are best for those of you in mental health settings.

They let you track:

• The patient’s behavior;
• What interventions you tried;
• How the patient responded;
• What’s next.

This framework helps capture detailed observations and responses, which is crucial for ongoing mental health care.

2. Make a list of must-have components

These frameworks give you a great starting point for structuring your notes, but they mainly focus on how to organize your information.

Now, you want to decide what specific details to include within that structure.

To make sure you cover everything without having to remember every detail, create a template that includes all the essential components for the cases you regularly deal with. These may include:

• Patient identification: the patient's name, date of birth, medical record number, and contact details.
• Chief complaint: the main issue or reason the patient is seeking care. 
• Review of systems (ROS): symptoms the patient is experiencing.
• Past medical history (PMH or Pmhx): Record any relevant past medical conditions, surgeries, or hospitalizations that could impact the current treatment.
• Medication history: list current medications, including dosages and any known allergies or adverse reactions.
• Family health history (FH or FamHx): any significant family health issues that could be relevant to the patient’s condition.
• Social history (SH or SocHx): information on lifestyle factors such as smoking, alcohol use, occupation, and living situation.
• Physical examination findings: the results of your physical examination.
• Exam results: any lab results, imaging studies, or other diagnostic tests that were performed.
• Plan: further actions including the treatment plan, additional tests, and follow-up appointments.

3. Learn medical abbreviations

Using commonly accepted medical abbreviations in your notes will save you a lot of time. It’s much more effective than writing everything out in full or creating your own shorthand, which can confuse others. 

You’ve already seen a few common abbreviations in the previous section, such as ROS, PMH, and others. Here are a few more examples:

• BP — Blood Pressure
• HR — Heart Rate
• C/O — Complains Of
• WNL — Within Normal Limits
• Rx — Prescription
• H&P — History and Physical
• PMH — Past Medical History
• Dx — Diagnosis

You can find a comprehensive list of medical abbreviations in medical textbooks and online medical dictionaries.

There are also many online databases that include more or less comprehensive lists of common medical terminology shorthands.

4. Use an AI scribe software

Making use of the right software can make a huge difference in streamlining your documentation process. AI and automation technologies are especially promising here.

A recent survey found that nearly half of healthcare professionals using AI and automation in their practice saw a noticeable reduction in the time their staff spent on paperwork. 

So how exactly does it work? AI in healthcare data management can be applied in various ways—from identifying outdated data to analyzing exam results.

But one of the simplest and most effective uses of AI is automating the note-taking process itself.

For example, AI-powered tools like Freed will capture, transcribe, and write your clinical notes.

How to use an AI scribe

1. Press the recording button at the start of a patient visit, and Freed will take care of the rest. 
2. Press stop once you're done; Freed will complete your note in about a minute.
3. Add in any edits, and Freed will learn to adapt to your style.
4. Copy and paste your note to your EHR.

Want to give it a try? Sign up to capture your first 10 visits for free.

5. Mind basic legal considerations

Depending on your role, you may be responsible for keeping your practice compliant with privacy regulations issued by local, state, and federal authorities.

But even those not directly responsible for establishing these policies must stay informed about the latest compliance requirements and understand how they impact daily operations.

In the U.S., the key law to focus on is HIPAA, which ensures that patients' medical records and health information remain confidential and secure.

Staying HIPAA-compliant means being mindful of where and how you access and share patient information. Here are some key practices to follow:

• Always use secure, encrypted methods when sharing patient information electronically.
• Be cautious with physical records, keeping them in secure locations and never leaving out where unauthorized individuals could access them.
• Limit access to patient information to only those who need it to perform their job.

State regulations also vary regarding how long you must store patient records. While HIPAA requires certain documents to be retained for six years, your local laws may mandate storage for longer—typically between six and 10 years.

To save yourself the trouble of managing compliance, only choose software that does it for you. 

Whether you're using electronic health records (EHR) systems or other digital tools to manage patient information, ensure that these platforms meet HIPAA's security requirements. The software should have robust encryption, secure access controls, and audit trails to track who accesses patient records and when.

Note: All AI models used by Freed are HIPAA-compliant and don’t retain data. It deletes patient notes automatically once note summaries and quality checks are complete or within 30 days. You can also delete records manually at any time. 

Create excellent clinical documentation, fast

One final piece of advice: keep your clinical records standardized. No matter how busy you are or how simple the case appears, strive to include the same level of detail in every note.

Write your notes as if another practitioner will be taking over the patient's care—and they’ll always be clear and easy to understand.

AI-powered note-taking software can help keep your notes consistent no matter what.

Try Freed today and capture accurate clinical notes in seconds.