Abstract Background There are no studies assessing the evolution and patterns of genetic studies performed at diagnosis in acute myeloid leukemia (AML) patients. Such studies could help to identify potential gaps in our present diagnostic practices, especially in the context of increasingly complex procedures and classifications. Methods The REALMOL study (NCT05541224) evaluated the evolution, patterns, and clinical impact of performing main genetic and molecular studies performed at diagnosis in 7285 adult AML patients included in the PETHEMA AML registry (NCT02607059) between 2000 and 2021. Results Screening rates increased for all tests across different time periods (2000–2007, 2008–2016, and 2017–2021) and was the most influential factor for NPM1 , FLT3‐ITD , and next‐generation sequencing (NGS) determinations: NPM1 testing increased from 28.9% to 72.8% and 95.2% ( p  < .001), whereas FLT3‐ITD testing increased from 38.1% to 74.1% and 95.9% ( p  < .0001). NGS testing was not performed between 2000–2007 and only reached 3.5% in 2008–2016, but significantly increased to 72% in 2017–2021 ( p  < .001). Treatment decision was the most influential factor to perform karyotype (odds ratio OR, 6.057; 95% confidence interval CI, 4.702–7.802), and fluorescence in situ hybridation (OR, 2.273; 95% CI, 1.901–2.719) studies. Patients ≥70 years old or with an Eastern Cooperative Oncology Group ≥2 were less likely to undergo these diagnostic procedures. Performing genetic studies were associated with a favorable impact on overall survival, especially in patients who received intensive chemotherapy. Conclusions This unique study provides relevant information about the evolving landscape of genetic and molecular diagnosis for adult AML patients in real‐world setting, highlighting the increased complexity of genetic diagnosis over the past 2 decades. A retrospective analysis of 7285 cases over 2 decades. This study explores the evolution of diagnostic practices in acute myeloid leukemia patients, highlighting factors influencing test implementation and their association with patient outcomes.