{"id":5363,"date":"2026-09-05T11:00:00","date_gmt":"2026-09-05T11:00:00","guid":{"rendered":"https:\/\/medivox.ai\/?p=5363"},"modified":"2026-08-31T21:08:40","modified_gmt":"2026-08-31T21:08:40","slug":"the-nursing-home-physician-and-the-medication-review","status":"publish","type":"post","link":"https:\/\/medivox.ai\/en\/sykehjemslegen-og-legemiddelgjennomgangen\/","title":{"rendered":"This is how the medication review in the nursing home becomes visible in the medical record"},"content":{"rendered":"

You have gone through the entire list, discontinued two medications, and adjusted one dose. The question is whether anyone can read that from the medical record afterward.<\/em><\/p>\n

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The nursing home visit has a completely unique pace. You go from room to room with a nurse beside you, and for each resident you must make an assessment that often spans eight diagnoses and eleven medications. You discuss falls, appetite, nighttime restlessness, and a blood pressure reading that is lower than last week. Then you move on. And at the end of the day you are left with a list of assessments that need to go into the medical record \u2013 from memory.<\/p>\n

For the nursing home doctor, documentation is not an attachment to the job. It are<\/em> the way the work becomes visible, both for the care staff who will follow up tomorrow, for the out-of-hours physician who is called in at night, and for the quality statistics that describe whether the residents receive the follow-up they are supposed to have.<\/p>\n

The requirement is clear \u2013 and the implementation demanding<\/h2>\n

After Regulations on medication management \u00a7 5a<\/a> must the institution ensure a systematic medication review for patients with long-term stays in nursing homes upon admission and at least once annually<\/strong> \u2013 and beyond that when necessary for the sake of proper treatment. The review is carried out by a physician, alone or together with other healthcare personnel.<\/p>\n

That is well-reasoned. The Directorate of Health points out that three out of four nursing home patients have one or more drug-related problems<\/strong>, and that the elderly are particularly vulnerable to side effects and adverse combinations. The most common change during a review is that a medication is no longer considered necessary and is discontinued.<\/p>\n

At the same time, the national quality indicator shows that 62.3 percent of residents aged 67 and older with long-term care had received a medication review in the past twelve months in 2025<\/strong>. The interesting thing is how the Directorate of Health itself explains the variation: one of the main reasons is that the information is not documented in the medical record - or that it are<\/em> documented, but not in the right place and in the correct format, so that they are not captured in the reporting. In other words: a good part of the gap is not about the job not being done, but about it not becoming readable to the system afterwards.<\/p>\n

It is a frustrating situation to be in. You have made a thorough professional assessment, but it disappears into a free-text field somewhere and is not counted.<\/p>\n

What a complete note should actually contain<\/h2>\n

The Norwegian Directorate of Health's national professional guidelines are specific about what the medical record note after a medication review should describe: the need for the review, where it was conducted, who participated, what was assessed, a list of justified measures in prioritized order, and a follow-up plan with a clear distribution of responsibilities. In addition, the medication list must be updated and shared with those assisting the patient.<\/p>\n

Uploaded like this, it is a fairly extensive note structure \u2013 multiplied by twenty residents on a visiting day. And this is where many recognize the problem: it is not the assessment that takes time, it is the recording of it. We have described the same pattern in the clinical pharmacist who reconciles medication charts<\/a> and at geriatrics with the complex patient<\/a>The more complex the patient is, the more the documentation requires \u2013 and the easier it is for something to be left out when it is written at the end of the day.<\/p>\n

The Medivox fits in<\/h2>\n

Medivox is designed to shorten the distance between the assessment and the note. You dictate while you are in the room or right after, and the system transcribes and builds a structured draft that you edit and approve. On ward rounds, this means that the rationale for every change \u2013 why<\/em> what you discontinued, what you will observe, who is following up \u2013 is included while it is fresh, instead of being compressed to \u00abdiscont. m.th., disc. zopiclone\u00bb at half past four.<\/p>\n

You build your own templates. A nursing home doctor rarely needs the same note structure as an outpatient clinic: one template for medication review, one for regular rounds, one for admission notes, and one for conversations with relatives. The templates are tailored to your practice, making it easier to hit the structure that makes the note retrievable\u2014both for your colleague and for reporting.<\/p>\n

Privacy is built in: directly identifiable information is pseudonymized before the data is processed further, and all data processing takes place in Norwegian data centers. And to be completely clear: Medivox takes no stance on the drug treatment. The tool documents the assessment you have already made. You own the record and make the final assessment.<\/p>\n

One perspective: the quality that is measured is the one that gets written<\/h2>\n

There is something a bit unfair about a resident who has actually received a thorough medication review appearing in the statistics as if she hasn't\u2014because the note ended up somewhere that isn't read automatically. That is not a problem the individual doctor can solve alone; it is about patient record systems, reporting formats, and municipal routines, and the Norwegian Directorate of Health is itself working to improve the data foundation.<\/p>\n

But what the individual can influence is how complete and retrievable the note becomes. And that is closely tied to how much energy is left when it is to be written. We have seen the same in the documentation work in home care services<\/a>when the threshold for writing goes down, the quality goes up \u2013 not because anyone tries harder, but because the note is written while the memory is intact.<\/p>\n

What would it have meant for your visit if the note had been finished the moment you left the room?<\/p>\n

Frequently Asked Questions<\/h2>\n

How often should a medication review be performed in a nursing home?<\/strong>
\nUpon admission and at least annually for long-term care patients, and otherwise when necessary for the purpose of proper treatment, cf. Section 5a of the Regulations on Medication Management.<\/p>\n

What should the medical record after a medication review contain?<\/strong>
\nThe need for the review, where it was conducted, who participated, what has been evaluated, justified measures in prioritized order, and a follow-up plan with the distribution of responsibilities.<\/p>\n

Does speech-to-text work during nursing home visits?<\/strong>
\nYes. You can dictate in the room or right afterwards, and get a structured draft that you quality-assure before it is added to the medical record.<\/p>\n

Is Medivox evaluating the medications for me?<\/strong>
\nNo. Medivox does not have clinical decision support. The tool documents the assessment you have made.<\/p>\n

What happens to the audio recording and the patient information?<\/strong>
\nDirectly identifiable information is pseudonymized before the data is processed further, and all data processing takes place in Norwegian data centers.<\/p>\n

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Use Medivox for free<\/strong> \u2013 Get started completely free<\/a><\/p>\n

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Do you work as a nursing home doctor and recognize the stack of notes after the ward round? Contact us<\/a> \u2013 then we will show you how a medication review can be documented while it is fresh.<\/em><\/p>\n

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Sources:<\/strong><\/p>\n