Clinicians spend up to 16 minutes per patient on EHR documentation, with much of that time consumed by writing or reviewing clinical notes (Annals of Internal Medicine)
Let that sink in. A task meant to support care now eats into it.
But here’s the catch: the answer isn’t just in writing faster – it’s in what happens after the note is written.
We don’t write clinical notes. We ensure they’re complete, compliant, and billable – after they’re written. That’s where the real transformation lies.
Clinicians and hospital leaders are looking at AI to speed up documentation – but what if the real opportunity isn’t how fast you write a note, but how well that note performs after it’s signed?
In this blog, we’ll unpack how ambient documentation is reshaping the future of the clinical note.
What Is a Clinical Note?
A clinical note is a written or electronic record of a patient encounter.
It captures symptoms, observations, assessments, plans and becomes part of the legal medical record.
So, when someone asks what is a clinical note? or What does a clinic note look like? – the answer is: it depends.
But whether handwritten or dictated, templated or free-form, clinical notes are the foundation of continuity, compliance, and coding.
Why Write Clinical Notes?
Let’s get the context right. Clinical notes aren’t just artifacts. They:
- Document medical decision-making
- Support continuity of care across visits and providers
- Protect against legal risk
- Enable billing and reimbursement
How to write a proper clinical note? The answer lies in knowing its audience: future-you, your peers, auditors, and algorithms.
Types of Clinical Notes
There are several formats depending on specialty and context:
SOAP Note
SOAP note stands for Subjective, Objective, Assessment, Plan. This is the most widely used format in medical documentation.
It structures the note into what the patient says, what the clinician observes, the diagnosis, and the treatment plan, making it easy to follow and audit.
DAP Note
DAP note stands for Data, Assessment, Plan.
Often used in behavioral health settings, this format simplifies the note by combining subjective and objective findings into “Data,” followed by clinical impressions and the plan. It’s fast and effective for routine sessions.
BIRP Note
BIRP note stands for Behavior, Intervention, Response, Plan.
Common in therapy and mental health practices, this format focuses on patient behavior during the session, the therapist’s intervention, how the patient responded, and the follow-up plan.
Narrative or Free-Text Notes
These are unstructured and allow providers to document freely in their own words.
They’re useful for complex cases or specialties like surgery, where rigid formats may not capture the nuance of the clinical scenario.
Examples of Clinical Notes
Primary Care Visit:
- S: Patient reports chest pain, 7/10.
- O: BP 130/80, tenderness on palpation.
- A: Likely musculoskeletal pain.
- P: Recommend rest, NSAIDs, follow-up in 1 week.
Mental Health Follow-up:
- S: Patient reports reduced anxiety; sleep improved.
- O: Affect bright, no psychomotor agitation.
- A: Stable on current regimen.
- P: Continue therapy, reassess in 2 weeks.
How to Write Better Clinical Notes
How to write a clinical note that’s clear, compliant, and concise?
Follow a structure
Most clinicians use the SOAP note format to keep documentation consistent.
Include Key data points
- Presenting complaint
- Relevant history (medical/surgical/social)
- Exam findings
- Assessment and plan
Avoid these pitfalls
- Vague phrases like “patient doing well”
- Copy-pasting old notes
- Missing timestamps or provider signatures
Use tools for validation
Once a clinical note is written, tools like Bulwark’s ARC+ steps in for pre-bill audits, using clinical AI to validate documentation, flag revenue-impacting gaps, and ensure risk-adjusted, denial-proof claims.
Progress Note vs Clinical Note
Progress notes are a type of clinical note focused on tracking patient status over time (e.g., during a hospital stay).
Clinical notes is the broader category encompassing everything from H & P notes to surgical narratives.
Think of progress notes as updates within a larger clinical documentation story.
Tips for Efficient Clinical Notes
Writing notes doesn’t have to drain your day.
- Write in the room if possible, even brief SOAP templates help
- Use templates and text expanders for repeatable phrasing
- Summarize, don’t narrate. Focus on what’s new or changed
- Time yourself, and aim to reduce the average note time by 10-15%
AI in Clinical Notes: The Good & the Hype
Let’s be honest. AI in clinical notes is hot right now. There are tools pioneering ambient documentation: AI-powered scribing that listens, interprets, and auto-writes notes during patient encounters.
That’s a big deal. But you know what can make it better?
Most ambient tools work best in low-complexity visits and require clean audio, consistent EHR integrations, and provider review. They help speed up input, but don’t catch what might be missing or non-billable in the note.
That’s where post-note tools like ARC+ come in: they review what ambient tools can’t – accuracy, completeness, risk adjustment capture, and compliance.
Ambient Documentation & The Future of the Clinical Note
Ambient documentation means notes without typing – AI listens in, captures context, and writes a draft.
So what’s the future?
1. Hybrid Models: AI drafts + human edits
2. Post-Visit Intelligence Layers: like ARC+, that optimize notes for billing and compliance
3. Context-Aware Smart Notes: that link vitals, labs, and meds to diagnosis pathways
Ambient documentation will reduce time spent writing notes. But the real transformation happens after the note is written when tools like Bulwark’s ARC+ step in to make sure it’s clean, complete, and billable.
FAQs
What does a clinic note look like?
Typically, it follows a SOAP or narrative format and includes patient complaint, exam, assessment, and plan.
What should be recorded in the clinical notes?
Subjective complaints, objective findings, assessment, plan, and relevant history. Always include timestamps and provider identifiers.
How can I write clinical notes faster?
Use templates, dictate when possible, and avoid over-documenting. Stick to what’s clinically relevant.
Can you use ChatGPT to write progress notes?
Not in regulated clinical settings, yet. You can brainstorm formats, structure examples, or summarize thoughts, but final documentation must follow legal and institutional policies.
Conclusion
The clinical note isn’t going anywhere, but how we create, analyze, and use it is changing fast.
From AI scribes to post-note intelligence like ARC+, the goal isn’t just faster documentation – it’s better outcomes, cleaner billing, and more time with patients.
If you are interested in a post-documentation intelligence layer that reads what’s written and ensures it’s audit-proof, accurate, and maximally billable, book a demo with Bulwark today.
