In 1793, doctors at New York Hospital logged patient notes in massive ledgers, armed with pen, ink, and a lot of patience.

Today, we've swapped paper for electronic health records (EHRs) and AI assistants. Still, the patient chart is a full-time job.

But no matter the format, your notes matter. They shape patient care, guide decisions, and keep everything running smoothly.

In this blog, we’ll explore how medical note-taking has evolved, why it’s essential (even if it gets its fair share of groans), and how you can spend less time documenting and more time doing what you love.

What are medical notes?

Medical notes are like small scraps of your ongoing health history.

They're written records of each patient visit, capturing symptoms, diagnoses, treatments, and follow-ups.

And as time goes on, your story gets more and more clear.

They serve as legal records and communication tools among healthcare providers, ensuring continuity of care and informed decision-making.

Types of medical notes

Here are the most common types of medical scribe notes:

• History and physical (H&P) examination
• Consultation notes
• Diagnostic test or lab result documentation
• Progress notes — usually in SOAP note format
• Preoperative and postoperative evaluation notes
• Operative or procedure notes
• Discharge summaries

Why SOAP notes work

We write SOAP notes to keep the medical record structured.

Developed by Dr. Larry Weed, the format organizes patient data clearly — separating facts from interpretation.

Clinicians rely on it because it’s structured, problem-focused, and improves continuity of care. 

Some clinicians prefer APSO (Assessment, Plan, Subjective, Objective), but the goal remains the same: a structured approach that supports patient-centered care.

📌 Related resource: What is the Benefit of Using SOAP Notes?

History and evolution of medical notes

Over centuries, handwritten notes have often been illegible, leading to false diagnoses or medication errors.

EHRs solved the legibility problem but introduced new burdens: click-heavy workflows, administrative overload, and “pajama time” spent catching up on charts at home.

Now, AI-driven tools automate note-taking and provide real-time clinical insights, reducing administrative load and restoring focus to patient care. From paper charts to intelligent automation, medical documentation finally works for clinicians — not against them.

Note: Unless stated otherwise, medical notes in this blog refer to digital notes.

Why are medical notes important for medical care?

Medical notes are more than documentation — they shape patient care, ensure compliance, and improve clinical workflows.

Digital notes, especially in EHRs, help with accuracy, accessibility, and efficiency, benefiting clinicians and patients.

Here's why doctor’s notes or clinical notes are essential in healthcare:

Ensure safe and effective care

Accurate, consistent notes guide treatment decisions.

💡 For example: when a patient with diabetes sees a primary care physician and an endocrinologist, aligned documentation of medication, labs, and past symptoms helps providers make informed decisions.

And according to a study, two out of three patients are more likely to follow medication plans after reading their doctor’s notes — reinforcing the importance of accessible, well-structured records.

Streamline collaboration

Medical notes help multiple providers stay on the same page — literally. By sharing detailed records, you reduce the risk of duplication or oversight.

Helps with regulatory compliance and provides legal protection

Detailed, time-stamped notes are vital evidence if legal questions arise, demonstrating due diligence and proper care. They protect healthcare professionals in malpractice claims and insurance disputes.

Assists in billing and insurance reimbursements

Insurance claims often hinge on accurate, detailed records. A well-documented patient encounter can speed up reimbursements and reduce administrative headaches.

Act as a bridge between the art and science of clinical documentation

Great medical notes balance human intuition and scientific precision.

“This is the practice of medicine. It determines what you do in the long run. You’re a victim of it, or you’re a triumph because of it.” — Dr. Larry Weed, Founder of Progress Notes

Good notes balance the art of storytelling with the science of structure — capturing patient narratives while keeping records clear, standardized, and actionable.

When merged skillfully, notes improve patient outcomes and strengthen clinician-patient trust.

Allows efficient analysis of medical records

With digital notes, patterns emerge. Researchers find better treatments, care teams make smarter decisions, and innovation moves faster — all because someone took good notes.

Common challenges in documenting medical notes

Digital documentation has improved accuracy, but it's also created a new burden. Here are some common challenges associated with making medical notes: 

• Time-consuming: Clinicians spend an average of 13.5 hours per week on documentation, with 3.2 hours spent outside work. Many take notes home, which cuts into personal time.
• Contributing to burnout: Excessive note-taking can feel like you’re constantly behind. Some surveys indicate that most physicians and nurses cite documentation burdens as a key factor in burnout.
• Risk of errors: Rushed or copy-pasted notes lead to missing, outdated, or incorrect information, making it harder to ensure accurate treatment.
• Repetitive workflows: EHRs require clinicians to enter the same details repeatedly, leading to bloated, inefficient notes. As Dr. Abraham Verghese put it, “Our daily progress notes have become bloated cut-and-paste monsters.”
• Reduced patient time: The shift to data-heavy EHRs means physicians spend more time face-to-face on computers than with patients, which is ironic for a profession built on human connection.

A smarter approach to writing medical notes: Advances in generative AI are reducing the burden of note-taking, automating documentation, and freeing up clinicians to focus on patient care.

AI scribes listen, transcribe, and structure notes in real time—eliminating manual data entry and helping clinicians reclaim their time.

Next, let’s explore best practices for writing medical notes efficiently.

Best practices for writing medical notes

Creating effective medical notes requires balancing comprehensiveness with clarity. Lalitha Mcsorley, lead Physical Therapist at Brentwood Physio, writes at least 15 detailed digital medical notes daily. Here is what she had to say about writing medical notes:

• Maintain clarity and accuracy: “We are dealing with patients’ healthcare here — mistakes can cause serious consequences.” Keep entries concise yet complete. Another clinician reviewing your note should immediately understand the key points.
• Use a standardized format: “Standardization is important so everyone can be on the same page with documentation.” SOAP remains popular because it’s structured and problem-focused.
• Maintain confidentiality and compliance: Follow HIPAA regulations by using secure platforms, logging out after use, and documenting consent before sharing records—even with other specialists.
• Be timely: “At my clinic, we require that all therapists enter a patient’s note within 24 hours of the visit to ensure the most accurate records.” Completing notes soon after a visit reduces errors and ensures you capture details while they’re fresh.

You should also take advantage of advancements in healthcare software. Voice-to-text tools and digital scribes can lighten your workload—no more endless clicking or retyping.

A bridge to better patient care

Medical notes have come a long way — from ink and paper to structured digital records. But even with EHRs, documentation can still feel like an uphill battle.

The good news? You don’t have to do it alone.

By using structured formats, finishing notes while details are fresh, and embracing AI-powered tools, you can reclaim your time and focus on what really matters—your patients.

Freed helps you do just that. It listens, transcribes, and organizes notes in real time, so you don't have to.

‍Sign up for Freed today and get a full week of free, unlimited notes.