A cancer process is not one consultation. It is twenty, fifty, a hundred — and a note written in March still makes sense in November.

You are in front of a patient you have met many times. It is treatment number six. She is clearly tired, and she says something you recognize from the last time, but you don’t quite remember how you formulated it. You flip through the journal. There are the notes, one per contact, each of them correctly written — and yet you have to read five of them to figure out what has actually changed since the summer.

This is what distinguishes long cases from short ones. In an emergency meeting, the note is a snapshot of a moment. In a cancer case, the note is one line in a story that you can read for yourself in half a year, by a colleague who takes over the shift, by the general practitioner who receives the epigraph, and by the patient himself.

Why documentation in the course of cancer is a unique challenge

Volume is part of the explanation. In 2025, it was recorded 40,364 new cases of cancer in Norway — for the first time the number passes 40,000 in one year — and at the end of the year they lived over 350 000 people who have had cancer during their lifetime, according to Cancer Registry's figures for 2025. Most of them are not finished with the healthcare service when the treatment is over.

The second part is that the process is distributed. The oncologist prescribes the treatment, but the nurse records the side effect, the radiologist describes the response, the GP handles what happens between the check-ups, and the home care team monitors how things are going in the evening. None of them has the full picture. The diary is the place where the picture is put together — and Patient record regulation § 4 says it almost verbatim: the journal is to provide an organized and comprehensive presentation of the patient's health condition, so that it is easy for healthcare professionals to understand the condition and further plan the healthcare provided.

«Comprehensive and organized» is a higher requirement than «correct.» Fifty correct notes can together be disorganized.

The four things that actually carry a long history

The regulations are specific about what may be relevant, and four of the points do a particularly good job in oncology.

The treatment plan and the status of its implementation (Section 6, letter d). Not only which course is chosen, but also where in the plan the patient is and what triggers the next step. Without this, the next person reading the plan has to reconstruct the plan from the notes.

Effect and side effects of the drug treatment (Section 6, letter e). In a course of repeated treatments, the history of adverse reactions is the very basis for dose adjustments later on. An adverse reaction that was noted during the follow-up in May is the information some are looking for in October.

The considerations behind a deviation from the guideline (Section 6, letter g). When you delay a course of treatment, reduce the dose, or choose something other than the action plan described, the justification is more important than the decision. That decision can be seen by others. The justification exists only if you wrote it down.

If the patient has minor children or siblings (Section 8, letter b). In the case of serious somatic illness, this is a separate documentation requirement, and it is one of the information items that is most easily omitted when the consultation involves blood tests and the next course of treatment.

In addition, there are administrative matters that do not feel like medicine, but that determine whether the course of treatment is coherent: who is the contact physician, who is the coordinator, whether there is an individual plan and where it is located (§ 5). We have written about this from the other side in the post about the one who keeps the thread when many are involved.

Life after the treatment should also have a place.

Package process at home for patients with cancer Something important moved into the formal process: the needs that lie outside The actual cancer treatment. All those diagnosed with cancer are included, regardless of whether the intention is curative or palliative, and patients with relapses are also included. The goal is, among other things, to ensure that the patient’s needs are «followed up through clear communication with other service providers, and the allocation of responsibility for further follow-up.».

The assignment of responsibility is a documentation task. If the conversation about work, finances, fatigue, or children has been conducted, but the conclusion is not recorded with a name, the municipality has no way of knowing that it has been carried out. Then it is done again — or not at all. The revised Package procedures for cancer from September 1st tightened up several of the same transitions.

The Medivox fits in

The problem with long processes is rarely that you don't know what should be included. It's that the consultation takes the time it takes, and the note is written afterwards — often several hours later, when the details have started to slip.

Medivox is a dictation tool. You dictate the review while it is fresh, and Medivox creates a draft journal note in a template you have created yourself. For oncology, this means that you can add fixed points to the template: the status in the treatment plan, side effects since last time, what has been agreed upon for the next course of treatment, who is following up on what. Then it’s not the memory that determines whether § 6, letters d and e, are covered — it’s the structure.

Some clarifications that are worth noting: transcription and generation are done by an AI service from OpenAI, and the processing takes place in the EU. Patient data is stored on our own servers in Norway, and the information is pseudonymized before the data is further processed. Medivox does not make any clinical assessments and has no decision support — the tool documents the assessment you have already made. You own the journal and make the final assessment.

The note that will be read about in half a year

A useful test when writing in a long passage: If I read only this note in six months, without remembering the patient — do I then know where we are, and what is going to happen next?

It’s not a question of longer notes. Often the opposite is true. It’s about the three or four lines that carry the narrative actually being there, every time, in the same place — and the rest being allowed to be short.

What is the one sentence you yourself are looking for when you open the record of a patient you haven't seen in three months?

Frequently Asked Questions

What must be included in the medical record for each course of treatment in a cancer process?
In addition to findings and assessments, the status of the treatment plan, the efficacy and side effects of the medications, and the justification for any deviations from the plan should be included. The Patient Record Regulations § 6 lists this as relevant and necessary information.

Do I need to document that the patient has minor children?
Yes, in cases of serious somatic illness, information about minor children or siblings is explicitly mentioned in the patient record regulations § 8, and is related to the Health Personnel Act § 10 a.

What is the difference between the cancer package process and the home package process?
The diagnosis-specific package processes apply to assessment and treatment. Package processes at home address the needs that go beyond treatment — work, coping, follow-up — and encompass everyone who receives a cancer diagnosis.

Does dictation work in an oncology clinic?
Dictation is the core function of Medivox, and the templates are created by you yourself. In outpatient procedures with many repeated contacts, it is precisely the fixed points in the template that make the notes comparable over time.

Who is responsible for ensuring that the follow-up after treatment actually takes place?
The package workflow at home emphasizes that responsibility should be clearly communicated to other service providers. In practice, this means that the conclusion must be recorded in the medical record with a name, not just as an intention.

Use Medivox for free – Get started completely free

If you work in a professional environment where the same patients are followed over the years, we would be happy to hear how you have solved the problems associated with repeated contacts. Contact us – We are happy to show you how to build your own templates.

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