Survey of revenue cycle executives points to the need to move from reactive to proactive clinical documentation

Hospitals and health systems need a more effective, sustainable approach to clinical documentation than reactive fixes — but most organizations aren’t being proactive enough.

Accurate clinical documentation is critical to healthcare organizations — not only in patient care, but also for compliance and financial sustainability. Yet despite advances in healthcare technology, as many as half of all clinical documentation improvement (CDI) and revenue cycle professionals say they’re still spending too much time fixing documentation errors at the point of care. 

That’s just one of several chief concerns flagged by a new HFMA survey of more than 100 CDI and revenue cycle professionals, which highlights a persistent problem: The traditional model of clinical documentation is still too reactive — and focused on fixing errors after the fact. ^[1]

And while CDI specialists can play an important emerging role in bridging the gap between documentation and coding, projected shortages of medical records specialists mean healthcare leaders may have a hard time finding the right staff. ^{[2] [3]}

The good news: The HFMA survey also reveals a strong shift toward proactive documentation strategies, which focus on aiming for accuracy before or at the point of care.

“So much clinical documentation is reactive today,” said Nate Wilson, president and cofounder of Regard, a health technology company with a clinical intelligence and documentation platform. “We wait for clinicians to review data, diagnose and document, and only then, we send a CDI query to clean things up later. That reactive approach only puts more burden on patients.”

Falling behind: The pitfalls of reactive documentation

More than 90% of HFMA survey respondents confirmed that their organization wants to prioritize improving documentation at or before the point of care, with 8 in 10 respondents believing a proactive approach would improve revenue and impact patient safety and care quality.

While these are laudable goals, organizations that are looking to be more proactive must first understand the pitfalls of their current approach — and why it’s probably not proactive enough.

As the HFMA survey suggests, health leaders aren’t certain about the extent to which their current technology stack is part of the problem. Two out of three believe they have the tools that support clinicians proactively, at the point of care, but half say their organization spends too much time fixing documentation errors after the fact.

One problem is that CDI tools alone aren’t enough to ensure timely, accurate documentation. Among the 155 respondents to the survey, nearly one in three respondents (28%) said current CDI tools definitely add to physician burden of care, while 34% said CDI tools might add to physician burden of care.

“What health systems are doing today is checking that data after the fact — a physician sees a patient, considers the diagnosis, documents it and then there’s this whole cascade of questions after that,” Wilson said. “At best, these actions are happening in real time, but decisions are still reactive to a physician saying, ‘I think they have heart failure.’ Even in the current best form of using CDI tools, the process is very reactive, and this puts the burden back on clinicians.”

Concurrent queries, which can only clarify documentation, still fall into the “reactive” category, he said.

“We’ve got 50,000 data points on every single patient now, so we far eclipse the human ability to keep up with this amount of data, and what we’ve discovered is that clinicians can only review about 3% of that data,” Wilson said, noting that this problem leads to misdiagnoses, lost revenue and suboptimal care. “Clinicians don’t have the means to see and review 97% of data.”

Given all the challenges healthcare organizations are facing already, dealing with the downstream impacts of documentation problems is unsustainable.

“We have less staff and need to be better partners with health informatics teams, with our physicians,” Wilson said. “We need to ask ourselves, ‘How do we move things up front, at the point of care, from a proactive documentation perspective that flows seamlessly into the CDI and revenue cycle?’”

Getting ahead: Moving toward proactive documentation

Given the enthusiasm for a more proactive approach, now is the time to take steps toward swapping out the processes and technologies that don’t support it. Here are three suggestions for getting started.

• Seek out common reactive scenarios. Assessing the extent of reactive “fixing” of clinical documentation errors is the best way to understand what’s at issue. For example, are documentation errors more common with patients over 65 with multiple comorbidities? And if so, why is that the case — and what can clinicians do differently?

• Prioritize physician engagement. As many as 94% of HFMA survey respondents emphasized the importance of clinical team collaboration. To improve engagement and collaboration, make sure physicians are on board with the organization’s plan to improve point-of-care capture through stronger collaboration between CDI teams and clinicians. 

• Implement AI tools that impact documentation at the point of care. Getting ahead of documentation prior to a clinical encounter can help avoid misdiagnoses and coding and billing errors later on. AI-based clinical​​ ​​decision support tools can help by ingesting and reviewing 100% of patient data (e.g., health history, symptoms) and leveraging machine-learning algorithms to recommend diagnoses, typically with about 99% accuracy. This brings supporting evidence into the patient encounter, Wilson said.
  
  “This automates documentation rules so that before a physician even sees their patient, they have a first draft that says, ‘I think your patient has these four diseases, and here’s a suggested treatment plan.’ This leads to better collaboration between clinical and health informatics teams and higher levels of accuracy,” Wilson said. “If the patient has ​systolic ​heart failure, specify it ​​at the point of documentation, ​​so teams don’t have to specify it later when a claim is flagged. This not only unlocks a massive time savings, but also new revenue.”

Making the shift

The joint HFMA Regard survey validates what many CDI leaders already sense: Proactive documentation improves documentation by focusing on how care is delivered and documented by the clinician. Now is the time for CDI and revenue cycle teams to rethink documentation as a proactive strategy rather than a back-end fix​ that ​adds to an already burdened clinical workflow.​​

​​“We have some CDI teams bringing AI-driv​​en ​​clinical decision support tools into their health systems precisely because they can’t operate in a reactive world,” Wilson said. “Even the biggest CDI teams can’t review 100% of patients, but if you’re not seeing 100% of patients, what’s being left behind? That’s what we need to focus on.”

About Regard

Regard,​ the leading AI-powered proactive documentation solution, unlocks the full potential of patient data. Regard empowers the future of healthcare by augmenting clinical workflows and turning data into actionable insights. The technology helps health systems get the most value out of their clinical data: improving patient care, saving physicians time, and enhancing hospital finances. Regard is leading the path forward for health systems and providers to meaningfully leverage AI, with the goal of empowering clinicians to provide world-class healthcare to everyone.

_{This published piece is provided solely for informational purposes. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions by participants are those of the participants and not those of HFMA. References to commercial manufacturers, vendors, products, or services that may appear do not constitute endorsements by HFMA.}

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Footnotes

^[1]. HFMA and Regard Survey, “Clinical Documentation Improvement Research Summary,” August 2025.

^[2]. AAPC, “What Is Clinical Documentation?”
January 2024.

^[3]. U.S. Bureau of Labor Statistics, “Medical Records Specialists,” updated Aug. 28, 2025.