Building Toward Patient-Level Representation
Clinical documentation has long served as both a record of care and a tool for communication. But as the volume and complexity of patient data have grown, the limitations of current note-based documentation have become painfully clear. At River Records, we’re working to build something better: a system that supports patient-level representation, where each clinical issue is tracked clearly, succinctly, and continuously over time.
From Notes to Problems
The traditional clinical note tries to do too much. It serves as a legal record, a billing artifact, a communication handoff, a memory aid, and a workspace - all at once. Unsurprisingly, it struggles to do any one of these well.
Most clinicians fall into one of two documentation styles:
Snapshot notes, which capture only what changed during an encounter. These are lightweight and quick but often omit valuable longitudinal context.
Cumulative notes, where each new entry pulls forward older text, rehashing past problems, labs, or plans. These are more comprehensive—but also more bloated, redundant, and difficult to maintain.
Both styles are valid responses to EHR limitations. But neither is sufficient for representing the true state of a patient’s health over time.
The Goal: Patient-Level Representation
Patient-level representation means organizing information not around visits, but around the problems we’re treating. Instead of scattering updates across disconnected notes, we’d track clinical issues in one longitudinal thread - allowing for clean, comprehensible summaries of any condition at any time.
Such a record would:
- Be problem-oriented, not note-oriented.
- Support micro-updates instead of redocumentation.
- Make it easy to generate accurate, timely summaries.
- Reflect how clinicians think - not how software is structured.
This isn’t just an efficiency play - it’s about clarity, safety, and better care.
R-SOAP: Our First Step
Our R-SOAP format is designed to move us closer to patient-level representation. By adding a Recap section to the classic SOAP note, R-SOAP allows Stream to show a running summary of what’s known about a problem - without forcing the clinician to repeat themselves in each encounter.
The Recap is written by AI based on past entries.
It’s editable, reviewable, and always contextual.
The rest of the SOAP note remains a time-stamped snapshot - focused on what’s new today.
In this model, we separate history from updates. You get the benefit of longitudinal clarity without the overhead of cumulative documentation.
Why This Matters
Recently, one of our team members—a practicing physician—was reviewing a specialist note. But the note didn’t just pull forward prior relevant history. It copied the entirety of the two previous notes into the current one.
That meant the note contained three separate assessments and three separate plans. There were no labels or clarifying markers. To figure out what was most recent, they had to go back and read the other two original notes—just to make sense of the one they were reading.
It was the height of inelegance in documentation: bloat, redundancy, poor communication, and duplication. The very thing the note was supposed to prevent—confusion—was built into its structure.
What’s Next
Patient-level representation isn’t a new concept—it’s the ideal that many of us have always aspired to. But for the first time, we have the tools to make it real.
With generative AI and thoughtful design, we can:
Maintain structured histories per problem
Enable targeted review and summary
Reduce duplication and prevent information loss
This is the vision we’re building toward at River Records. And every R-SOAP note brings us one step closer.
If documentation is going to evolve, it has to serve the clinician—not just the system.
Want to see what patient-level representation looks like in practice?
Check out Stream and try it for yourself.
