AI scribe and clinic software for occupational therapy

The occupational therapy note, function first

The OT note is organised around what the person does. It starts with the reason for referral and an occupational profile, the patient's roles, routines and what matters to them, then the functional assessment of personal care, domestic tasks, transfers and mobility, a cognitive and perceptual screen where relevant, the environment and the risks. Standardised measures such as the Canadian Occupational Performance Measure or the Barthel Index give the goals a baseline. wai reads the same captured note in SOAP, problem-oriented or narrative view, and the clinic's templates are shared across every therapist.

Home assessment is guideline work. In its 2025 falls guideline, NICE recommends offering a home hazard assessment and intervention using a validated tool, and says to consider having an occupational therapist carry it out.¹ For people who have fallen in the last year and have a gait or balance problem, it recommends a falls prevention exercise programme and considering a home hazard assessment.¹ The template carries a field for each room and each hazard, so the report reads the same for every patient.

Measurements have to be said. An ambient scribe captures speech, so the toilet height, the bed height, the step depth and the door width enter the note when the therapist says them aloud as they measure. The same applies to how a transfer looked, which the therapist describes as it happens.

Codes come from the note. wai suggests ICD-10 and SNOMED CT codes, each beside the line of the consultation it rests on, for the therapist to confirm. Referrals and insurer reports typically carry codes such as I69.3 for sequelae of cerebral infarction, G35 for multiple sclerosis, M06.9 for rheumatoid arthritis, F82 for specific developmental disorder of motor function and R29.6, which the WHO ICD-10 titles tendency to fall and US ICD-10-CM titles repeated falls. Evaluation and treatment codes, CPT in the US, stay with the clinic's biller.

Reports and letters, to whom and what they carry

The home assessment report goes to the patient and family, with a copy to the GP. The Academy of Medical Royal Colleges recommends writing most outpatient letters directly to the patient with a copy to the GP, and says that should be the default setting for an AI scribe.⁶ For an OT, the patient's version explains what was found room by room, what equipment is recommended and why, and who will fit it, and the equipment list carries the specifications someone else needs to order it. That report runs as a clinic template, or a bespoke template on the Clinician Plus plan.

Work advice goes on the fit note. Department for Work and Pensions guidance lists occupational therapists among the professionals who can certify fit notes, and asks the professional to consider other duties, altered hours or workplace adjustments before advising that a patient is not fit for any work.² wai drafts UK fit notes on the official form from the session, with the adjustments in the comment box, for the therapist to sign.

Private OT work runs on formal reports. Solicitors and case managers instruct care and equipment needs reports after injury, and wai drafts medico-legal and expert reports from the record, held for the therapist to sign and downloaded as a PDF. Referral letters, to a falls exercise programme, physiotherapy or the GP, carry the question for the next professional, as the referral letter describes.

Assessments in the patient's own language

A home visit often includes the family, and the family may not speak English. wai works in 60 languages, among them English, Arabic, Spanish, French, Portuguese, Italian, Russian, Polish, Turkish, Urdu and Mandarin. English can be mixed in one session with Spanish, French, Portuguese, Russian, Italian, Dutch, German, Hindi or Japanese, and the other languages are captured in that language.

The signed report is written in English for the record, or in another language the clinic chooses, and the patient's summary of what was found and what to change at home can be translated into their language beside it, with emergency numbers kept exactly as written. With the patient's consent, a son or daughter who coordinates care can have carer access to the letters and the plan. The multilingual scribe page explains the detail.

Clinic software for occupational therapy clinics, from home visit to review

OT practices run on visits out of the clinic. Patients, families and case managers request appointments through booking links that read each therapist's calendar, reminders go out before each home visit, and cancellations are offered to the waitlist. Video sessions work too, and the scribe joins Google Meet, Zoom and Microsoft Teams calls.

Money runs through the clinic's own Stripe account, with deposits, payment links and invoices to insurers for funded work. Calls, email, web forms and WhatsApp land in one thread per patient, so a case manager's question and a family's question sit beside each other, and a person approves every drafted reply before it is sent.

Equipment is where follow-up slips. The after-visit companion tracks each referral and follow-up until it is done, and wai's proactive care sends a recall for the review visit once equipment should be in place, each message approved by a person. Before the review, the therapist sees a sourced brief of the last assessment and recommendations, each fact traced to the report it came from. The clinic management software page covers the front desk.

One home assessment, start to finish

Take an 81-year-old woman who lives alone and has fallen twice at home in six months, referred by her GP. Her daughter joins the visit. She speaks Polish, and the session is captured in Polish. She says she no longer uses the bath because she is afraid of stepping over the side, and that she gets up twice a night to use the toilet.

The therapist narrates the visit room by room. Two steps up to the front door with no rail, a loose rug in the hallway, no light switch at the bedroom door, a bath with no grab rail, and a toilet seat measured at 38 cm with the patient pushing up hard from the sink to stand. They agree a rail at the front steps, removing the rug, a plug-in night light, a bath board and grab rail, a raised toilet seat and a referral to a falls prevention exercise programme, with a review once the equipment is fitted.

The draft report lists each room, each hazard, each measurement and each recommendation with its reason. It had recorded the toilet seat as 40 cm, and the therapist corrected it to the 38 cm she had measured. wai suggested R29.6 and R26.8 for abnormalities of gait and mobility, and the therapist confirmed both and signed.

What went out was the report to the patient with a Polish summary beside the English, a copy to her GP, the equipment list with specifications, and a referral to the falls exercise programme. The front desk sent the invoice, gave her daughter carer access with the patient's consent, and set a recall for the review visit in four weeks.

The evidence behind wai's method

The note is one part of the day the evidence measures. In a randomised trial of 238 outpatient physicians across 14 specialties at UCLA Health, the ambient scribe with a significant effect cut the time spent writing each note by about 41 seconds, against 18 seconds in usual care.⁴ At The Permanente Medical Group, 3,442 physicians used an ambient scribe across 303,266 encounters in its first ten weeks.⁵ Occupational therapists were not studied, and an OT's hours sit in reports more than notes, so wai drafts the report, the equipment list and the fit note from the same session.

The regulator asks for complete, prompt records. The HCPC standards, in effect since 1 September 2024, require full, clear and accurate records for everyone the registrant cares for, completed promptly and as soon as possible after care.³ wai holds every draft until the therapist signs it.

The patient's own language. In a systematic review of 33 studies, 76% found at least one outcome better when patient and physician shared a language other than English.⁷

Measured in a working clinic. At The Wellness in London, which runs on wai every day, every clinician has 15 hours a week back, as published in the customer story.⁸

Where to start

Start with home assessments for one therapist. In week one, build the home assessment template with a section for each room, fixed fields for each measurement and an equipment list with specifications, and measure the time from leaving the house to a signed report. In week two, add the patient summary in the patient's language, fit notes for work cases and recalls for equipment reviews, and count corrections to measurements.

Then add functional assessment and case manager report templates. Compare the workflow with the allied health guide and the geriatrics guide, see every profession on the specialties hub, and read how the scribe works on the wai Clinicians page.

Frequently asked questions