Real-time documentation

Tidstro dokumentation - real-time documentation - means writing the note while the observation is still fresh, not two hours later at the office and not at the end of the shift. It is also where the Danish elder-care reform and the ministerial Partnerskab for Bedre og Mindre Dokumentation are heading: documentation with the citizen, and only when there is something real to write down.

That requires a tool that is fast enough and discreet enough to be used at the point of care. That is what Clex is built for.

Why it is hard today

On a normal shift in home care or a nursing home there is a stream of small observations that should end up in the record: changed skin, a different gait, less appetite, a remark from a relative. In practice this only gets written down when the care worker is back at a computer - if they still have time and can still remember.

• The phone keyboard is too small and too slow to type free-text notes about clinical observations while providing care.
• The care worker has to switch between talking with the resident and choosing the right words for the record. For the 42% of Danish frontline care staff whose first language is not Danish, that is an extra layer of work.
• Free-text fields pressure staff to write more than the deviation warrants - so the note gets put off.
• Privacy: a phone that reads a note aloud in the resident’s living room is a problem. A documentation tool with no answer to that situation is a problem.

The result: observations are either delayed or lost. Those that feed into early detection and the integrated care plan are recorded only when the day is nearly over - if at all.

What real-time documentation looks like in practice

• The note is written while the care worker is still with the resident, or immediately after.
• The note is short. It is a deviation note, not a summary of the visit.
• The resident can be part of it - the note can be read aloud before it is saved.
• The language matches the record system, not the care worker’s everyday speech.
• Nothing is written when there is nothing to write.

This is what principles 4 and 5 of the Partnerskab call for: document with the citizen, document only deviations and changes.

How Clex supports it

Clex is a keyboard on Android and iOS, and a browser extension on Chrome and Edge. Staff write inside their own record system, not inside a separate app. The tool is designed around the short, real-time note:

• The pictogram marks the observation. Staff pick the body area, condition, or care situation that is actually different today. This takes seconds, not minutes.
• Care-specific word suggestions above the keys. Trained on Scandinavian care documentation rather than generic phone autocomplete, they guide staff to the correct clinical term quickly.
• A sentence suggestion kept to deviation-note length. Not a paragraph. The care worker accepts, edits, or rejects.
• On-device read-aloud before saving. The care worker hears the note - and can read it aloud to the resident, so the resident can be part of the note-taking. Read-aloud runs on the device, not in the cloud.
• Direct translation to the native language. Staff who do not have Danish as a first language can check that the Danish sentence means what they wanted to document. The translation runs entirely on the device.

The same mechanism that makes Clex fast enough to use at the point of care also keeps the note at the length the reform calls for. A vendor built for long free-text or for dictating the whole visit would need a fundamental redesign to achieve real-time documentation. Clex does not.

What this means for care leadership

For a care leader, real-time documentation is not only a quality consideration - it is a resource consideration. When notes are written in the moment, the end-of-shift documentation backlog disappears, along with the time that deferred documentation currently takes away from direct care and oversight. Staff no longer end the shift carrying a list of half-remembered observations.

For IT: Clex does not depend on the cloud to function in real time. Read-aloud and translation run on the device; only the text the staff member types passes through the Clex API. Real-time behaviour does not depend on stable connectivity in the resident’s home.

Further reading

See also Early detection - the discipline built on real-time documentation. Clex and the Ældrelov explains how Clex supports the Danish reform. The FAQ answers the questions procurement, DPOs, and IT most often ask.