The conversation took place on a walk around the lake, or at the kitchen table in the user's home. It was professional, it was important – and it needs to be documented. Just not right now.

Municipal mental health and substance abuse care has a way of working that differs from most else in the healthcare service. The meetings often take place outside the office. They last longer than a consultation. They rarely have a clear start and end. And they are just as much about relationship and everyday coping as about defined clinical issues.

It does something to the documentation. Not because the requirements are different – they are not – but because the distance between when something happens and when it can be written down often large.

The requirements also apply here

It is worth stating the starting point, because it is sometimes unclear in practice. Health Personnel Act § 39 states that the person providing healthcare must record or register information in a medical record for the individual patient. Section 40 adds that the medical record must be kept in accordance with good professional practice, contain relevant and necessary information about the patient and the healthcare provided, and be easy for other qualified healthcare personnel to understand.

That also applies when help is provided on a park bench.

The Norwegian Directorate of Health's national guide Mental health and substance abuse work for adults which is a revision and professional update of «Together on Mastering» – recommends that the municipality organize the service offering in three main courses, from knowledge-based low-threshold services (main pathway 1) to treatment tailored to severe and long-term disorders in cooperation with the specialist health service (main pathway 3).

And the supervisor is clear about the duty that comes before all of this: municipality shell assess the need for assistance for adults who present with mental health or substance use problems. An assessment that is not documented is difficult to build a care pathway on – and even more difficult to hand over.

Where the documentation actually falls short

The challenge is rarely willingness or competence. It is practical.

You are out in the field for most of the day. You have had four meetings, two of them unexpectedly long, one of them with an acute concern you had to handle right then and there. It is half past three, and you are sitting in front of the electronic health record system with four conversations in your head at the same time.

What is written then is almost always correct. But it is compressed. The observation that made you change your assessment, the wording the user themselves used about how things are, the small change in sleep or contact surface that you noticed – things like that often do not survive a six-hour delay and three other patients.

The consequence is not felt the same day. It is felt when a colleague takes over, when specialist healthcare services ask about the background history, or when it needs to be assessed whether a treatment pathway has actually had an effect.

This is a known burden across occupational groups. We have written about it as documentation fatigue – the invisible energy leak that comes from having to remember and recreate instead of recording. And we have seen the same mechanism in social educators documenting milieu therapy work, where the most important thing is often the least schematic.

Among psychologists, the effects have been visible enough to be quantified – we mentioned it in the post about the documentation crisis in mental health care. It is not quite the same framework as in the municipality, but the mechanism is the same: conversations that are difficult to summarize, written down long after they ended.

The Medivox fits in

Medivox is built for the gap between the conversation and the written record. You dictate while the meeting is fresh—ideally in the car on your way to your next appointment, or right after you've left the home—and get back a structured draft of a clinical note that you edit and approve later. The point is not to document more, but to avoid having to recreate it from memory.

You build your own templates. That matters in this service, where the notes from a home visit, an assessment interview, and a follow-up in main pathway 3 have different content. The template can reflect the structure your service actually uses, rather than a generic patient record template.

And some clarifications that belong here: Medivox does not have clinical decision support, and does not make any assessments of the user's condition, risk, or needs. The tool documents the healthcare you have provided. You own the medical record and make the final assessment. Directly identifiable information is pseudonymized before the data is processed further, and all data processing takes place in Norwegian data centers – which is worth knowing when the content is as sensitive as it is in this field.

One perspective: the one who does not have their own entry in the system

Municipal mental health and substance abuse work is one of the services rarely mentioned when health technology is discussed. Attention goes to hospitals, general practitioners, and EHR systems. We have previously written about the professions that are forgotten in health digitalization and mental health workers, substance abuse counselors, and milieu therapists in the municipality definitely belong there.

That is a shame, because it is precisely here that tools which remove friction in documentation have the greatest impact. Not because the most time is saved per note, but because the quality of what is written directly affects whether a treatment trajectory holds together when multiple people are contributing.

What would have been in your note if you could have written it immediately after the conversation – and what is in it today?

Frequently Asked Questions

Do employees in municipal mental health and substance abuse services have a duty to document?
Yes, when health care is provided. Section 39 of the Health Personnel Act applies to anyone providing health care, regardless of whether it takes place in an office or out in the field.

Which guideline applies to the field?
The Norwegian Directorate of Health's national guideline «Mental Health and Substance Abuse Work for Adults,» which is a revision and professional update of «Together for Coping.» It was last updated professionally in February 2025.

Does speech-to-text work when conversations happen outside the office?
Yes. You can dictate right after the meeting, while it is still fresh, and edit and approve the draft later on your PC.

Can I create my own templates for mapping and follow-up?
Yes. In Medivox, you build your own templates and can switch between them depending on the type of meeting.

Does Medivox assess the user's risk or needs?
No. Medivox does not have clinical decision support. The tool documents the work you have done; the mapping and assessment are yours.

Use Medivox for free – Get started completely free

Do you work in municipal mental health and substance abuse services and write your notes long after the conversation has ended? Contact us – then we'll show you how you can get the draft finished while the meeting is still fresh.

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