You end a therapy session at 15:45.
The next patient arrives at 16:00.

In these 15 minutes, you will document a 50-minute conversation that may have included strong emotions, relational conflicts, therapeutic interventions and clinical assessments.

For many psychologists, this means a daily dilemma:

Should you write a thorough journal note and risk being delayed to the next patient?
Or write shorter and hope you get the most important points across?

Record keeping is a necessary part of sound professional practice. At the same time, many psychologists find that documentation is gradually taking up more and more of their working hours.

In this article, we take a closer look at why record keeping in psychology is demanding - and how new AI-based tools can make documentation both faster and more precise.

Why journaling in psychology takes time

Conversations in psychotherapy are complex. A therapy session can involve several parallel processes: the patient's narrative, emotional reactions, therapeutic interventions and the psychologist's clinical assessments.

A good journal note must therefore document more than just what was said in the session. It must also provide a professional description of the assessments on which the treatment is based.

In practice, this means that journal notes often contain:

• assessment of the patient's condition

• therapeutic interventions

• the patient's response

• assessment of further treatment

This type of documentation is important for the continuity of treatment, especially if the patient is later followed up by other therapists.

What does the law say about psychologists' record keeping?

In Norway, record keeping is primarily regulated by Health Personnel Act §39, which states that healthcare professionals have a duty to keep records for patients who receive healthcare.

Source:
https://lovdata.no/dokument/NL/lov/1999-07-02-64

In addition, the Patient Journal Regulations. requirements for what the journal should contain.

Source:
https://lovdata.no/dokument/SF/forskrift/2019-03-01-168

Among other things, the medical record must document information that is necessary to provide proper health care. This includes assessments of the patient's condition, relevant measures and plans for further follow-up.

For psychologists, this often involves more extensive and reflective notes than in many other medical fields.

When memory isn't enough

A common solution is to write the journal entry later in the day. The problem is that details from a conversation quickly disappear from memory.

Already in the 19th century, the psychologist showed Hermann Ebbinghaus how information is gradually lost after an incident if it is not repeated or documented.

Source:
Ebbinghaus, H. (1885). Memory: A Contribution to Experimental Psychology.

For psychologists, this can mean that important nuances from a therapy session are lost if the note is written several hours later.

How AI can make record keeping easier

In recent years, artificial intelligence has made great strides in speech recognition and language understanding. This makes it possible to use transcription and automatic text generation in clinical documentation.

In practice, this can work like this:

During the therapy session, the conversation is automatically transcribed. At the end of the session, the psychologist can generate a structured journal note based on the transcription.

The note can then be reviewed and edited before being entered into the journal system.

This type of workflow allows the documentation to be done immediately after the session - without the psychologist having to write the entire note manually.

Less duplication in clinical practice

Another challenge many psychologists recognize is that the same information often has to be written several times in different documents.

A journal note can later become the basis for referrals, assessments or discharge summaries.

This topic is also discussed in the article:

https://medivox.ai/henvisning-fra-journalnotat-slutt-a-skrive-alt-to-ganger/

When information is structured correctly from the start, much of this duplication can be reduced.

Privacy and AI in mental health care

Psychological records contain some of the most sensitive information in healthcare. That's why data security is crucial when adopting new technological tools.

In Norway, such solutions must meet the requirements of:

• General Data Protection Regulation (GDPR)

• health legislation

• requirements for information security in the health service

Medical AI is developing rapidly, and new models are becoming increasingly efficient and secure.

You can read more about this here:

https://medivox.ai/ki-modellene-blir-raskere-mindre-og-flytter-hjem/

Want to see how it works in practice?

Every Wednesday, Medivox hosts a short webinar where we show how healthcare professionals use speech-to-text for record keeping.

You can sign up here:

https://events.medivox.ai/#events

Frequently asked questions about record keeping for psychologists

Do psychologists have to keep records?

Answer. According to Health Personnel Act §39 healthcare professionals have a duty to keep records for patients who receive healthcare.

Source:
https://lovdata.no/dokument/NL/lov/1999-07-02-64

What must a journal note from a therapy session contain?

The medical record must contain information that is necessary to provide proper health care. This includes assessments of the patient's condition, relevant measures and plans for further follow-up.

Source:
https://lovdata.no/dokument/SF/forskrift/2019-03-01-168

Can psychologists use AI for record keeping?

Yes, as long as the tool is used as an aid to documentation and privacy and data security requirements are met.

The psychologist is always responsible for the content of the journal.

Can AI replace the psychologist's professional assessment?

Well, no. AI can help with transcription and text structuring, but clinical assessments and treatment decisions must always be made by the psychologist.

Does the patient have to consent to the use of AI in record keeping?

In many cases, AI is used as an internal documentation tool, similar to dictation or speech-to-text.

Nevertheless, it is good practice to be open about how records are kept.

Conclusion

Journaling is an important part of psychological practice - but it doesn't have to be the most time-consuming.

By using modern transcription and automated documentation tools, psychologists can reduce the time spent on administration while making records more accurate.

In a working day where many people are experiencing increasing documentation requirements, such tools can help move more of the time back to the most important things:

work with patients.