Clinician-controlled notes in paediatric OT: a Perci case study

Setting

Practise: Paediatric occupational therapy
Session types: Individual & group therapy
Environment: Outdoor, high-noise, play-based sessions
Clinicians involved: Occupational Therapists (OTs) & Allied Health Assistants (AHAs)

Background

A paediatric OT practice was exploring whether a clinical scribe could reduce documentation burden while maintaining high-quality, clinically meaningful notes.
Although the potential benefits were clear, the team had understandable concerns about whether a scribe could perform effectively in paediatric sessions, given their fast paced, child-led structure, and variable environments.

Their concerns were grounded in everyday clinical reality:

• Sessions were highly play-based and child-led
• Much of the clinical reasoning was observational rather than verbal
• Sessions frequently involved:
  • Outdoor environments
  • Multiple children
  • High levels of background noise
  • Dysregulation, movement, yelling, and non-linear activity

The practice was already using an Allied Health Assistant (AHA) to manually document sessions, which provided a useful benchmark.

Approach

To evaluate whether Perci could meet paediatric documentation standards, the practice ran a parallel note-taking trial:

• AHAs continued writing session notes, as usual
• Perci was used concurrently to generate session summaries and action plans
• Sessions included:
• Group and individual therapy
• Outdoor activities (bike riding, creek play, gardening)
• Sensory regulation, fine motor, self-care and emotional regulation tasks

Clinicians compared notes for:

• Clinical relevance
• Accuracy of observations
• Ability to capture dysregulation and emotional responses
• Usefulness for ongoing planning
• Effort required to review and finalise

Key Clinical Concerns Being Tested

The practice specifically wanted to understand whether Perci could:

• Capture play-based therapy, where progress is observed through behaviour rather than conversation
• Remain coherent during dysregulation, including yelling, movement, and emotional escalation
• Handle group sessions, where attention shifts rapidly between children
• Produce notes that supported clinical reasoning, not just activity lists

What the Practice Observed

Play-based therapy was documented with clinical meaning
Perci linked activities to the therapeutic purpose and recorded observations about regulation, engagement, endurance, and skill development that occured within unstructed play.

Dysregulation was captured accurately
Even in noisy, high-movement sessions (yelling, escalation), Perci still summarised what triggered dysregulation, how it presented, and how it affected participation without losing the thread of the session.

Group sessions were clearer
Perci differentiated each child’s role and skill focus, while also documenting shared tasks and overall group goals.

Notes were ready to use
Compared with AHA notes, Perci’s outputs were more structured, clinically relevant, and action-oriented, and typically required minimal edits, while clinicians still retained full control to review and finalise.