A psychologist was reported to the Health Authority. Out of 76 therapy sessions, only two journal entries were found. The case is not unique – it is symptomatic of a profession caught between therapeutic presence and the duty to document.

The therapy room vs. the keyboard

As a psychologist, you know that presence is everything. Eye contact, listening, the therapeutic alliance – all of that which research shows is crucial for treatment outcomes. Studies published in the Journal of Psychology confirms that the alliance between therapist and client is one of the strongest predictors of good treatment outcomes.

But then comes the documentation requirement. The Patient Journal Regulations and The Healthcare Personnel Act §§ 39-40 Requires you to document the date, reason for contact, examination findings, clinical assessments, diagnostic considerations, and treatment plan – for every single consultation.

The result? Many psychologists put off record-keeping. Notes are written in haste after a long day with patients, or in the worst-case scenario – they are never written.

When the journal is missing: The consequences are real

In 2024, the professional portal Psykologisk.no published the article «Therapists neglect record-keeping», which revealed that the problem is far more widespread than one might think. Patients who request access to their medical records often receive an almost empty document in return – after years of treatment.

The Norwegian Board of Health Supervision has cracked down hard on this. In a well-known supervisory case, a private practicing psychologist received a warning after it was discovered 2 journal entries from 76 treatment hours for two years. The Health Supervisory Authority considered this a violation of the requirement for proper care – because without documentation, the treatment cannot be considered proper either.

This is not just about bureaucracy. Lack of record-keeping can have consequences for:

  • Patient Safety Without documentation, it is impossible to ensure continuity of care, especially when changing therapists or in acute situations.
  • Oversight cases: The Norwegian Board of Health Supervision considers the medical record the primary evidence of proper treatment.
  • Patient Rights: Patients have a statutory right to access their medical records. An empty record is a breach of trust.

The Journal in a New Era: The Patient Reads Along

With the introduction of electronic access to patient records, the rules of the game have changed. A recent text analysis published in the Journal of Psychology (2025) aim for journals in mental healthcare to be shaped by several considerations – clinical documentation, legal safeguarding, and communication with the patient who is now reading what you write in real time.

This places new demands on how psychologists express themselves. The record must be professionally precise, but also understandable and respectful to the patient reading it. A demanding balancing act that takes time.

AI Tools for Psychologists: A Promising but Demanding Landscape

Several actors have tried to solve the documentation challenge with technology. The Norwegian company Kipler.ai developed a tool that transcribed therapy sessions and generated journal notes adapted to different therapeutic approaches. However, in 2024, it was revealed VGs testing at the tool «hallucinated» in the therapy room – with significant errors in diagnostic analysis. Kipler withdrew from the market.

This experience highlights an important point: AI tools for health documentation must be built with security and accuracy as top priorities. The tool must never alter patient data without explicit approval from the clinician, and it must be transparent about what is a transcription and what is an AI-generated suggestion.

Another approach: Dictation that preserves presence

There's an option between writing everything manually and letting AI interpret your therapy session. Medical speech-to-text technology allows you to dictate your medical notes in your own words, right after the session – while the conversation is still fresh in your memory.

Medication MediVox Can you:

  • Dictate journal notes in Norwegian with medically accurate recognition
  • Structure the notes according to your preferred template
  • Use breathing module for referral letters and discharge summaries
  • Maintain full control over your content – no AI «interpreting» your therapy

You decide what is written. Technology just makes the writing faster.

From backlog to control

Proper record-keeping doesn't have to mean sacrificing your presence in the therapy room. But it does require a system that makes documentation feasible – not just mandated.

MediVox can try for free with three generations per day. The standard subscription costs 599 SEK/month and provides access to all features. For those who want to take back your time without compromising on quality.

Have you experienced challenges with record keeping in clinical practice? Learn more about how MediVox works for psychologists, or contact us for a no-obligation demo.

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