Write on paper, wrong in practice: Why LLMs still struggle with writing clinical notes

Large Language Models (LLMs) are often proposed as tools to streamline clinical documentation, a task viewed as both high-volume and low-risk. However, even seemingly straightforward applications of LLMs raise complex sociotechnical considerations to translate into practice. This case study, conducted at KidsAbility, a pediatric rehabilitation facility in Ontario, Canada examined the use of LLMs to support occupational therapists in reducing documentation burden.We conducted a qualitative study involving 20 clinicians who participated in pilot programs using two AI technologies: a general-purpose proprietary LLM and a bespoke model fine-tuned on proprietary historical documentation. Our findings reveal that documentation challenges are sociotechnical in nature, shaped by clinical workflows, organizational policies, and system constraints. Four key themes emerged: (1) the heterogeneity of workflows, (2) the documentation burden is systemic and not directly linked to the creation of any single type of documentation, (3) the need for flexible tools and clinician autonomy, and (4) effective implementation requires mutual learning between clinicians and AI systems. While LLMs show promise in easing documentation tasks, their success will depend on flexible, adaptive integration that supports clinician autonomy. Beyond technical performance, sustained adoption will require training programs and implementation strategies that reflect the complexity of clinical environments.