EmadDSalehi/MTS_dialoge_FT huggingface dataset:
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: MEDICATIONS

Dialogue:
Doctor: So I have here that you're taking three different medications.
Patient: Yeah. I've been taking them every day just like they told me to.
Doctor: I see. That's good. Did you refill your prescriptions with the newly revised doses? It looks like they changed the dosing of your medications at the hospital.
Patient: Um I've just been taking what I have at home.
Doctor: I advise that you take the doses that they prescribed. If you'd like me to put in a new order, please let me know.
Patient: Okay, yeah that's fine. I can pick it up on my way home. I didn't think the dosing mattered much as long as I took the meds every day.

assistant: I reviewed his medication list in the chart. He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTSURGICAL

Dialogue:
Doctor: Any major surgeries in the past?
Patient: Not too many, but a catheter was put in my heart.
Doctor: Oh, so cardiac catherization, correct?
Patient: Yep.

assistant: No major surgery except for prior cardiac catheterization.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Guest_family: Doctor, you must tell her. She has stopped taking her medications. And her blood pressure is out of control, she is angry all the time and not looking after herself at all.
Patient: That is not true!
Doctor: Miss Tara, you need to take your medications on time. You are hypertensive and your readings don't look good.
Patient: I don't want to take anymore medications. I want to try some natural remedies to treat my high blood pressure. I am not going to take any prescription meds that's it.
Doctor: If that's the case then I will make note in your file that you are not complying.

assistant: Hypertension. The patient noncompliant
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: CC

Dialogue:
Patient: I think I got some allergy, my lips are swollen and its causing me difficulty in swallowing.
Doctor: Oh, let me take a look.

assistant: Swelling of lips causing difficulty swallowing.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Any medical history?
Patient: Um I suffer from depression and high blood pressure.
Doctor: Are you taking anything for either?
Patient: Only for high blood pressure.
Doctor: Have you had surgeries in the past?
Patient: I had surgery to get a few hemorrhoids removed back in two thousand and ten.

assistant: Significant only for hemorrhoidectomy. He does have a history of depression and hypertension.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: How's your family?
Patient: They're doing well, thank you. My three boys are all grown up. Hard to believe they're living their own as young professionals. One of them is actually a G I doctor in San Diego, California.
Doctor: You must be so proud of your boys.
Patient: My wife and I always say how lucky we are.
Doctor: I'm sure. And I have a few more questions before we wrap up.
Patient: Go for it.
Doctor: Do you drink or smoke?
Patient: I smoke about a third of a pack a day and I drink every now and again, but nothing crazy.

assistant: The patient still smokes about a third of a pack a day, also drinks only occasional alcoholic drinks. The patient is married. She has three grown sons, all of which are very successful in professional positions. One son is a gastroenterologist in San Diego, California.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: How's it going, buddy? I haven't seen you in a long time
Patient: Hey, Doctor. It's been a while. I've been doing well. Just here for my check up.
Doctor: Nice. How's the family doing? Are they all well?
Patient: Yeah, they're doing great. Nobody has been sick for a while.
Doctor: That's great to hear. Nobody has new medical conditions either, right?
Patient: Not that I know of. They're all doing good.

assistant: Reviewed and unchanged.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: So, you and your husband live together, correct?
Patient: Yes. It's a miracle we've lasted this long.
Guest_family: Can't argue that.
Doctor: Are you able to walk any distance without assistance?
Guest_family: She's most comfortable in her wheelchair, but she usually walks with a walker if she's at home.
Patient: Yeah, he's right.
Doctor: And how often do you walk with your walker?
Patient: If I were to guess, I'd say half the time.
Doctor: Great.
Guest_family: If I'm nearby, I like to keep any eye on her incase she feels unstable and needs help sitting back down.
Doctor: It's good that you're both looking out for each other. Now moving onto the last few questions. Do you smoke or drink?
Patient: No and no.
Doctor: Did you smoke or drink in the past?
Patient: No.

assistant: She lives with her husband, usually walks with a walker and wheelchair-bound, does not walk much as per the husband knows. No history of alcohol abuse or smoking.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: CC

Dialogue:
Doctor: You do not look so well today. What seems to be the problem?
Patient: Well‚ I am having a hard time. My whole body aches and I am in pain.
Doctor: Do you have a history of drug use?
Patient: Well yes. I am detoxing.
Doctor: What kind of drugs have you been using?
Patient: Heroin.
Doctor: Okay. How long have you been using?
Patient: I don't feel well. Maybe a year. I can't sleep or eat.
Doctor: Have you had a fever, chills, vomiting or diarrhea?
Patient: I think I have a fever. I feel chilled. I have had some diarrhea.

assistant: Detox from heroin.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: How would you rate your general health?
Patient: I've been in reasonably good health at least physically. I try to go on frequent walks and eat a clean diet. However, there was one instance where I was not well mentally. After my husband died in nineteen seventy five, I had what I believe was a nervous breakdown. As a result of this, I was hospitalized for several weeks and treated with E C T.
Doctor: I'm so sorry to hear about the loss of your husband. I can't imagine how difficult that must've been. I'm glad that you sought the care that you needed to feel better at that time. Did this happen when you were living in the United States or Korea?
Patient: This all happened when I was living in Korea. I'm grateful that I had my family and friends to support me.
Doctor: Social support is very important, especially when you are processing the loss of a loved one.
Patient: Absolutely.
Doctor: I have a few more questions before we move on. Any past medical problems?
Patient: I used to have high blood pressure.
Doctor: When you say used to, do you mean it's been resolved now?
Patient: Yes.
Doctor: Great news. How about surgeries? Have you had any in the past?
Patient: None whatsoever.
Doctor: Any alcohol or tobacco?
Patient: No, I stay away from things like that.

assistant: The patient has generally been in reasonably good physical health. She did have a "nervous breakdown" in 1975 after the death of her husband. She was hospitalized for several weeks and was treated with ECT. This occurred while she was living in Korea. She does not smoke or drink alcoholic beverages. She has had no prior surgeries. There is a past history of hypertension, but this is no longer present.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ROS

Dialogue:
Doctor: Are you experiencing any headaches, or do you have any history of migraine?
Patient: No.
Doctor: Any temporary loss of consciousness?
Patient: No.
Doctor: Any feeling of being off balance or fainting?
Patient: No.
Doctor: Any continuous sound you may hear?
Patient: No.
Doctor: Okay so no tinnitus. Any mouth sores or ulcers?
Patient: Um, no.
Doctor: Do you notice any change in your voice, any hoarseness?
Patient: No, nothing like that.
Doctor: Did you notice any swelling in and around your mouth?
Patient: No, I did not.
Doctor: Any history of goiter or swelling of your thyroid gland?
Patient: Nope.
Doctor: Okay.

assistant: HEENT: No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Hello, miss. How can I help?
Patient: Well, I just turned fifty seven this year and I would like to get rid of these wrinkles on my face. I don't like them one bit.
Doctor: You look beautiful and actually have a lot of fullness in the face. It is great that you do not smoke and do not have history of skin disease. We can definitely help you with these minor issues.

assistant: This 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids. In summary, the patient is a healthy 57-year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and mid face region and prominent nasolabial folds.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Good afternoon, ma'am.
Patient: Good afternoon, doctor.
Doctor: Remind me, how young are you?
Patient: Oh doctor, you flatter me. I'm sixty two years old.
Doctor: Great, and you've had a rotator cuff repair before, correct?
Patient: Yes, that's correct.
Doctor: Good, well, what seems to be the problem today?
Patient: I'm still having a lot of pain in this shoulder.
Doctor: Oh no, have you had any recent imaging done on this shoulder?
Patient: Yes, I had an M R I not too long ago, can you take a look? I have it right here.
Doctor: Thank you, yes, um, this M R I shows that you've torn that rotator cuff again.
Patient: Oh no, can we do another surgery to repair it again?
Doctor: Yes, we'll have to.
Patient: What's the risk of infection of the surgery?
Doctor: Its less than one percent. We'll use antibiotics to control for infection the entire time.
Patient: Will I be asleep again?
Doctor: Yes, you won't feel a thing.
Patient: Great, yes, I'd like to go forward with the surgery. I need to get back to playing tennis.

assistant: This is a 62-year-old female who previously underwent a repair of rotator cuff. She continued to have pain within the shoulder. She had a repeat MRI performed, which confirmed the clinical diagnosis of re-tear of the rotator cuff. She wished to proceed with a repair. All risks and benefits of the surgery were discussed with her at length. She was in agreement with the above treatment plan.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: What brings you in today?
Patient: I dropped a glass and one of the broken pieces cut my foot pretty badly. There was a lot of blood.
Doctor: Is the area still bleeding?
Patient: I got it to stop bleeding while I was waiting for my ride.
Doctor: Is there any pain in the area?
Patient: No, it doesn't hurt.
Doctor: Are you able to walk normally without pain or discomfort?
Patient: Yes.
Doctor: Are you experiencing any numbness or loss of strength in the area?
Patient: No.
Doctor: Do you have any other injuries on any other part of your body?
Patient: No.
Doctor: Have you had any recent illnesses?
Patient: No.
Doctor: Do you have any other concerns while you are here today?
Patient: No.

assistant: This is a 32-year-old male who had a piece of glass fall on to his right foot today. The patient was concerned because of the amount of bleeding that occurred with it. The bleeding has been stopped and the patient does not have any pain. The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort. The patient denies any injuries to any other portion of his body. He has not had any recent illness. The patient has no other problems or complaints.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: What do you do for a living, sir?
Patient: I'm actually retired, but I used to work as a dock hand.
Doctor: That's great, congratulations on your retirement!
Patient: Thank you so much, doctor.
Doctor: I just need some background information on you, sir. Do you smoke?
Patient: Sure, I smoke about a half a pack of cigarettes a day.
Doctor: Do you drink, sir?
Patient: Well, not anymore, but I used to be an alcoholic.

assistant: 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PROCEDURES

Dialogue:
Doctor: Any surgical history?
Patient: I had my thyroids taken out.
Doctor: When did you have them taken out?
Patient: Hm three years ago. Man, time flies.
Doctor: Did you experience any complications post surgery?
Patient: Nothing out of the ordinary.
Doctor: Who was the surgeon who did your thyroidectomy?
Patient: Doctor X.
Doctor: What was the final diagnosis?
Patient: I had a growth on my thyroids.
Doctor: Was the growth cancerous?
Patient: It was. I was initially reluctant to get them out, but I realized it was necessary. I didn't have much of a choice if I wanted to live ya know.
Doctor: That's understandable. I'm sorry you had to go through that. Surgery is daunting, let alone surgery to remove cancer.

assistant: Total thyroidectomy.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Welcome in. I am Doctor Welch.
Guest_family: Thank you! It is nice to meet you.
Doctor: How old is your daughter?
Guest_family: She is three years old now.
Doctor: Hi there!
Patient: Hi!
Doctor: Mom I would like to start off with some questions regarding pregnancy, childbirth, and prior children.
Guest_family: Okay.
Doctor: Do you have any other children?
Guest_family: No. She is my only child.
Doctor: Have you ever had any miscarriages or abortions prior to having your daughter?
Guest_family: I had a very early miscarriage before getting pregnant again with her.
Doctor: I am so sorry to hear that.
Guest_family: Thank you. I was difficult but when I got pregnant again with her, we were so overjoyed.
Doctor: Did you have any difficulties or problems during your pregnancy with her.
Guest_family: I had the flu in my seventh or eighth month of pregnancy. Other than that I had no problems.
Doctor: How far along were you when you gave birth?
Guest_family: I was thirty six weeks.
Doctor: Did you have a vaginal birth or a C section?
Guest_family: I had a regular birth.
Doctor: Were any tools used during the birth to help with the birthing process?
Guest_family: No.
Doctor: How long were you in labor for?
Guest_family: I was in labor for eleven hours.
Doctor: Were you given any anesthesia during the birth?
Guest_family: They gave me a little bit of laughing gas but not much.
Doctor: What was her birth weight?
Guest_family: Seven pounds and ten ounces.
Doctor: Do you recall her Apgars score?
Guest_family: No. I am not sure.
Doctor: How long did you stay in the hospital after the birth?
Guest_family: Five days.
Doctor: Let us move to questions regarding your daughter. Has she had any development problems?
Guest_family: She did not walk until well after two years old. She only rolled from side to side at two.
Doctor: Okay. How old was she when she spoke her first words?
Guest_family: She was around one or two.
Doctor: When did she start to feed herself, using her hands?
Guest_family: She was two.
Doctor: Has she been toilet trained yet?
Guest_family: No. She is not interested but I have been trying.

assistant: Spontaneous Vaginal delivery at 36weeks gestation to a G2P1 mother. Birth weight 7#10oz. No instrumentation required. Labor = 11hours. "Light gas anesthesia" given. Apgars unknown. Mother reportedly had the "flu" in the 7th or 8th month of gestation. Patient discharged 5 days post-partum. Development: spoke first words between 1 and 2 years of age. Rolled side to side at age 2, but did not walk. Fed self with hands at age 2 years. Never toilet trained.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Okay and are you working?
Patient: Oh yes, I am a farmer. I have a farmland and my wife, and I do farming.
Doctor: Good, so you are one happy married couple working together.
Patient: Ah, yes.
Doctor: And how about tobacco, do you smoke or eat?
Patient: Absolutely not.
Doctor: Any use of drugs or alcohol?
Patient: Drugs?
Doctor: Yeah, like cocaine or anything like that.
Patient: Oh that, no. No drugs.
Patient: And I don't drink either.
Doctor: Alright.

assistant: Farmer, Married, no Tobacco/ETOH/illicit drug use.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: EXAM

Dialogue:
Doctor: Well, looking at your hand x ray, the bone looks in alignment, and I don't see any effusion.
Doctor: Any tenderness or pain?
Patient: Ah, not really!
Doctor: There is no asymmetry. Can you move your hand up and down? Now rotate it. Can you move your fingers?
Patient: Yes, I can do all of that, no problem at all.
Doctor: Can you bend your hand?
Patient: Yes.
Doctor: Perfect.

assistant: BONE: No misalignment, asymmetry, defect, tenderness or effusion. Capable of from of joint above and below bone.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTSURGICAL

Dialogue:
Doctor: How about any surgeries in the past?
Patient: Well, I had colon surgery in nineteen eighty nine or was it ninety, oh yeah in nineteen ninety.
Doctor: Okay and anything else?
Patient: Ah yes, I had three surgeries for my sinus one was the same year as my colon surgery, one was before that. So, the first one was in nineteen eighty seven I believe then nineteen ninety and the last one was in two thousand five.
Doctor: Wow, you remember the years also.
Patient: Yeah, surprisingly.

assistant: Colon resection in 1990 and sinus surgeries in 1987, 1990 and 2005.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: So, do you drink or smoke, sir?
Patient: I'd say I have the occasional drink, but I don't smoke.
Doctor: What do you do for a living?
Patient: I'm a nursing aid in a nursing home right now.
Doctor: Do you work the normal day shift?
Patient: No, I work the second shift, so I work some late nights and early mornings.
Doctor: Are you back at Wichita State this semester?
Patient: No, I decided to take some time off.
Doctor: Is everything okay?
Patient: Yeah, I'm just really tired, so I decided to step away for a little.
Doctor: That's understandable. Are you dating right now?
Patient: Yes, I've been dating my boyfriend for a while now.
Doctor: Is there any significant stress in your relationship?
Patient: No, everything is going really well.

assistant: Only occasionally drinks alcohol and he is a nonsmoker. He currently is working as a nurse aid, second shift, at a nursing home. He states that he did not enroll in Wichita State this semester. Stating he just was tired and wanted to take some time off. He states he is in a relationship with one partner and denies any specific stress in the relationship.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: What brings you in today, miss?
Patient: I haven't been feeling well since I went to the dentist.
Doctor: When did you go to the dentist?
Patient: It was in May last year.
Doctor: What happened at the dentist? Also, sorry, but how old are you.
Patient: It was after I left the dentist. I was driving home, and I got lightheaded. I was so lightheaded that I had to pull over.
Doctor: How long did the episode last?
Patient: About two to three minutes.
Doctor: Is this the only time that this has happened?
Patient: No. In November last year, I was in the middle of eating breakfast when I got dizzy. I was so dizzy that I was nauseous, and I threw up several times. I was so exhausted from the dizziness and throwing up that I went to my room and took a two hour nap. I felt better and back to normal after I woke up from my nap.
Doctor: How long did the vertigo last?
Patient: It lasted about two to three minutes. So, about the same amount of time.
Doctor: Have you had any other dizzy episodes?
Patient: No I didn't but in January on the thirteenth my right arm went numb. It lasted for about four to five hours.
Doctor: Are you left handed, or right?
Patient: I am right handed.
Doctor: Have you experienced any slurred speech or trouble swallowing?
Patient: No.
Doctor: Have you had any continuing weakness other than the time in January?
Patient: No.
Doctor: Have you experienced any headaches or visual changes?
Patient: No.
Doctor: Any continuing vertigo or lightheadedness?
Patient: No.

assistant: This 61y/o RHF experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. In 11/92, while eating breakfast, she suddenly experienced vertigo. This was immediately followed by nausea and several episodes of vomiting. The vertigo lasted 2-3minutes. She retired to her room for a 2 hour nap after vomiting. When she awoke, the symptoms had resolved. On 1/13/93 she had an episode of right arm numbness lasting 4-5hours. There was no associated weakness, HA, dysarthria, dysphagia, visual change, vertigo or lightheadedness.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Oh wow, you got stung quite a few times.
Patient: Yeah, you're right about that. In my seventy six years this i have never gotten stung. This is new.
Guest_family: He got stung around noon while I was inside preparing lunch.
Patient: Yeah, they got both my hands and right knee. Those little monsters.
Doctor: Did you notice redness and swelling right away?
Patient: Um not right away.
Doctor: How long did it take for your body to react?
Patient: Bout thirty minutes or so.
Doctor: Did you experience any shortness of breath, itching, or hives?
Patient: No, surprisingly.
Doctor: And no tongue swelling or trouble swallowing?
Patient: No.
Doctor: Have you gotten stung in the past? Or is this your first time?
Patient: I got stung about a month ago. No redness or swelling like I do now. I guess it could've been due to the Benadryl I took as soon as it happened.
Doctor: Did you take Benadryl again today?
Patient: No, I figured I'd be okay.
Guest_family: He takes Metoprolol and Hydrochlorothiazide for his blood pressure.
Patient: And a baby Aspirin in the mornings.
Doctor: Did you take your daily medications today?
Patient: Yeah."

assistant: Patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today. He did not note any immediate reaction. Since that time, he has noted some increasing redness and swelling to his left hand, but he denies any generalized symptoms such as itching, hives, or shortness of breath. He denies any sensation of tongue swelling or difficulty swallowing. The patient states he was stung approximately one month ago without any serious reaction. He did windup taking Benadryl at that time. He has not taken anything today for his symptoms, but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTSURGICAL

Dialogue:
Doctor: Any major or minor surgeries done in the past?
Guest_family: Sorry, I have no idea about it.
Guest_family: I just started working for him.

assistant: Unknown.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: MEDICATIONS

Dialogue:
Doctor: I can see your medication list here.
Doctor: Do you take Accutane and Ovcon?
Patient: Yes, I do.
Doctor: Okay.
Patient: Okay.

assistant: Accutane and Ovcon.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Guest_clinician: Hello, doctor. Let me give you a run down as to what we are dealing with today. This patient was last seen in January two thousand and four. She is coming for a follow up on interstitial disease secondary to lupus pneumonitis. I will let her tell you more about what happened yesterday.
Doctor: Thanks, nurse. How are you feeling today, miss? Welcome back to the Pulmonary Medicine Clinic. What happened yesterday?
Patient: Well, I was doing fine since last time. My respiratory issues have been great and I have had no major difficulties breathing.
Doctor: That's good to hear. What happened yesterday that caused you to want to come in so urgently?
Patient: Yesterday I noticed that I have some back and joint pain. When I breathe deep my back hurts.
Doctor: Are you experiencing any coughing?
Patient: No, coughing at this moment.
Doctor: Have you been producing any mucus the times that you do cough?
Patient: No, I already said I didn't cough.
Doctor: Okay. Any fevers or chills?
Patient: Nothing so far.
Doctor: Do you have any other symptoms currently?
Patient: I do notice that I am more tired than usual.
Doctor: During physical activity do you seem out of breath or more tired than usual? I want to see if your pulmonary system is inhibited.
Patient: No. I don't have issues with breathing when I do daily activities.

assistant: The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis. She was last seen in the Pulmonary Medicine Clinic in January 2004. Since that time, her respiratory status has been quite good. She has had no major respiratory difficulties; however, starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort. She denies any problems with cough or sputum production. No fevers or chills. Recently, she has had a bit more problems with fatigue. For the most part, she has had no pulmonary limitations to her activity.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Hello sir, it's been a while since your last visit. How have you been?
Patient: Hello doctor, yes, I have come a long way. I guess last time I was here was in two thousand and two if I am not wrong. Was does your system say?
Doctor: You are right! It was August second of two thousand and two to be very precise.
Doctor: Please confirm for the records, you are a white married man and must be forty nine years old now. Am I right?
Patient: You got it all right doctor!
Doctor: Are you still working in that airplane company?
Patient: Yes sir, still with Alaska Airlines but I have been promoted and work as a plane mechanic.
Doctor: That is so nice! Good for you man! So, tell me how can I help you today? What brought you to our dermatology department today?
Patient: I'm having pain in my stomach on the right side and down here.
Doctor: Is it only on the right side or anywhere else?
Patient: It is on both sides and now I can feel it on the middle part of my left thigh as well.
Doctor: Tell me more about it. How did it start? When did you first notice it?
Patient: It's been going on and off. It was not there for a while, but now it is like back again mainly on my tummy, down here. It is painful when I touch it. At first, I thought maybe I'm having shingles.
Doctor: When did you notice it?
Patient: It all started before the holidays, I think one and a half months before the holidays. It is still going on for the past eight days in my tummy and the hips mainly on the right side.
Doctor: Did you get any treatment for this? Any over the counter medicines?
Patient: No, as I told you I thought it was shingles, but then there was no change in the skin, no rashes, nothing. I was not sure what to take.
Doctor: Okay, do you bathe every day?
Patient: Yes, I do but I try to use as little soap as possible.
Doctor: Okay, here is what I think, all your symptoms are pointing towards hyperesthesia. I would like to run some tests to find the underlying cause and then we will start the treatment. A nurse will come and take you to the lab. Does this sound good to you?
Patient: Yes.

assistant: This 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh. It cleared for awhile. This has been an intermittent problem. Now it is back again on his right lower abdomen. At first, it was thought that he may have early zoster. This started six weeks before the holidays and is still going on, more so in the past eight days on his abdomen and right hip area. He has had no treatment on this; there are no skin changes at all. The patient bathes everyday but tries to use little soap. The patient is married. He works as an airplane mechanic.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: IMAGING

Dialogue:
Doctor: Are you finished with your cancer treatments?
Patient: Yes. I am in remission now.
Doctor: That is great! When was your last radiation treatment?
Patient: It has been over two years since my last treatment.

assistant: She has had no recent radiological procedures.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you smoke?
Patient: Yeah. I smoke about a pack a day.
Doctor: Do you have any plans of quitting?
Patient: Eh not really.
Doctor: As your doctor, I'd advise that you consider nicotine patches and find ways to break your smoking habit.
Patient: Okay. I'll see what I can do.
Doctor: Do you drink?
Patient: Socially.
Doctor: Are you married?
Patient: No, but I have two littles ones.
Doctor: Aw, how old are they?
Patient: I have a four year old and a six year old.
Doctor: That's great. I'm sure they keep you busy. Any hobbies?
Patient: They really do, especially the four year old. As for hobbies, I like fixing up computers. I also like fishing, hiking, and camping with the family.

assistant: He smokes one pack of cigarettes per day. He is a social drinker. He is not married, but has two children. Hobbies: Computers, hiking, camping, fishing.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Good morning, ma'am. Before we begin today, can you confirm your age for me?
Patient: Good morning, doctor. Sure, I'm seventy nine years old.
Doctor: Great, thank you. What seems to be the problem today, ma'am?
Patient: Well, I have this arthritis, as you know.
Doctor: Yes, how would you describe your arthritis?
Patient: Well, at this point I'd say it's debilitating.
Doctor: I see, so the antiinflammatories and rest haven't helped at all?
Patient: No, I haven't had any improvement, doctor. It's still so bad.
Doctor: I see, I believe you'd be a good candidate for a knee replacement.
Patient: Yes, I thought so. What are the risks of infection for the surgery?
Doctor: Um, it's less than one percent, we use prophylactic antibiotics to control for infection the entire time.
Patient: That's great, what about anesthesia, will I be asleep for this?
Doctor: Yes, you won't feel a thing.
Patient: Great, yes, I'd like to do the surgery, doctor.

assistant: This is a 79-year-old female who has disabling bilateral knee degenerative arthritis. She has been unresponsive to conservative measures. All risks, complications, anticipated benefits, and postoperative course were discussed. The patient has agreed to proceed with surgery as described below.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Welcome to the clinic.
Patient: Thank you.
Doctor: Are you from the area?
Patient: I was born and raised in Iowa. My husband and I moved here twenty years ago, and we have been here ever since.
Doctor: It is a wonderful city. Do you have kids?
Patient: Yes! We have two kids.
Doctor: Do you have any history or present use of tobacco, alcohol and recreational drugs or substances?
Patient: I have a glass of wine every once and a while but no to the rest.

assistant: Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any h/o Tobacco/ETOH/illicit drug use.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Any of your family members have issues like seizures?
Patient: None on my father's side, but, yeah, on my mom's side some of the family members had seizures. Like, my mom had them during her childhood. I know that my great grandmother had it and so does my great aunt.

assistant: There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt. There is no other significant neurological history on the paternal side of the family.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Can you tell me what are the diseases you have been diagnosed with in the past?
Patient: Sure, I have had hypertension, diabetes, asthma and cholesterol problem.
Doctor: Ok, is there anything else?
Patient: Nope.
Doctor: And it is type two diabetes, right?
Patient: Yes.
Doctor: Thank you!

assistant: Significant for hypertension, type 2 diabetes mellitus, asthma, and high cholesterol.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Good afternoon, sir. Do you remember the details of your surgery?
Patient: No, can you remind me?
Doctor: Well, um, we did a right orchiectomy due to your testicular cancer, when did you have that?
Patient: Um, it was about eighteen years ago now, so that was about nineteen eighty nine.
Doctor: Good, while you're here, do you have any other conditions that I should be aware of?
Patient: Sure, I have G E R D, and um, I B S.
Doctor: Thank you, what about allergies, do those bother you?
Patient: Yeah, unfortunately I have those.
Doctor: Do you have them in the spring, or in the fall?
Patient: Actually, I have them in both. It's really annoying.
Doctor: What allergy symptoms do you have usually?
Patient: Um, another doctor called it a postnasal drip.
Doctor: Okay, yes, I'm familiar with that. Have you ever had any other surgeries?
Patient: Yeah, um, I had a hernia removed and repaired some time ago.
Doctor: I see, what about any other major medical conditions?
Patient: I've had carpal tunnel before.
Doctor: Which hands did you have it in?
Patient: I've had it in both.

assistant: Status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, GERD, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: How old are you?
Patient: I'm eighty six years old.
Doctor: What gender do you identify with?
Patient: I identify as a female.
Doctor: How long have you had this back and buttock pain?
Patient: Its been a while, now. I know I have a fracture in my lower back.
Doctor: How have you been managing this?
Patient: Another doctor called this conservative treatment. I've been resting a lot, and using antiinflammatories.
Doctor: Has there been any improvement?
Patient: Its been several months at this point, and honestly no, there's been no improvement. I'm still in a lot of pain.
Doctor: This C T Scan you had recently shows sclerosis, with some healing of a L five compression fracture, but if you look here, the healing is not complete.
Patient: What can we do about this? I'm in so much pain.
Doctor: I believe you'd be a candidate for a bilateral L five kyphoplasty.
Patient: What's that?
Doctor: It's a small procedure on that L five vertebra. Its minimally invasive, and we can actually do it as an outpatient procedure.
Patient: Oh, wow, that's good to hear. What are the risks of infection?
Doctor: Very low, historically, they're less than one percent.
Patient: How is this possible?
Doctor: We'll use antibiotics in order to control for infection.
Patient: That's great, will I be under anesthesia?
Doctor: Yes, you'll be asleep for the whole thing.
Patient: Great, yes, I'd like to have this done, I can't keep living in this pain.
Doctor: Awesome, I agree. Do you have control over your bladder and bowel movements?
Patient: Yes, thankfully, I have complete control over everything like that still.
Doctor: Do you wear a brace or corset normally?
Patient: Yes, I usually wear both.
Doctor: Okay, last question, can you notice any weakness in your body?
Patient: No, I'm still very strong, even at my age.

assistant: The patient is to come to the hospital for bilateral L5 kyphoplasty. The patient is an 86-year-old female with an L5 compression fracture. The patient has a history of back and buttock pain for some time. She was found to have an L5 compression fracture. She was treated conservatively over several months, but did not improve. Unfortunately, she has continued to have significant ongoing back pain and recent CT scan has shown a sclerosis with some healing of her L5 compression fracture, but without complete healing. The patient has had continued pain and at this time, is felt to be a candidate for kyphoplasty. She denies bowel or bladder incontinence. She does complain of back pain. She has been wearing a back brace and corset. She does not have weakness.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Good afternoon, sir, and who's the patient today? You, or your daughter?
Guest_family: Not me today, its my daughter.
Doctor: And how old are you, dear?
Patient: I'm eighteen.
Doctor: What seems to be the problem today?
Patient: I hurt my right knee while playing tennis, um, it was about three days ago now. It really hurts.
Doctor: I see, tennis, huh? Was there any contact involved?
Patient: No, I took a step wrong when I went for an awkward shot.
Doctor: Are you able to stand on this knee?
Patient: Not well, it feels unstable, like I'm going to fall over.
Doctor: Have you ever hurt this knee before?
Patient: Yeah, tore my ACL in two thousand eight.
Doctor: I assume you had surgery for that?
Patient: Yeah I did, um, with Doctor X. He called it an, um, A C L reconstruction.
Doctor: How did you recover from this?
Guest_family: She didn't do well, she didn't do what we or the others doctors suggested, and the knee never really got the same tightness back.
Doctor: What did they do about that?
Guest_family: I have it in my notes here, they did an, um, A C L revision. That was done by Doctor Y.
Doctor: When was that done?
Guest_family: Looks like it was at the end of two thousand eight.
Doctor: Following the revision, how did you cover?
Patient: I did everything they said, I did it exactly as they wanted, and I did fine until this last injury.
Doctor: Good, was there any instability following the revision?
Patient: Nope, I was really stable.

assistant: The patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury. She states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling. At this time, she complains of pain and instability in the knee. The patient's past medical history is significant for having had an ACL injury to the knee in 2008. She underwent anterior cruciate ligament reconstruction by Dr. X at that time, subsequently in the same year she developed laxity of the graft due in part to noncompliance and subsequently, she sought attention from Dr. Y who performed a revision ACL reconstruction at the end of 2008. The patient states she rehabbed the knee well after that and did fine with good stability of the knee until this recent injury.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: How're you feeling today?
Patient: Much better. The antibiotics seemed to really help.
Doctor: Are you still experiencing any symptoms?
Patient: Um no, thankfully. I had some wheezing when I first started the antibiotics, but it's improved a ton. I don't think the wheeze is even there anymore.
Doctor: Good, good.

assistant: He has had some wheezing in the past but nothing recently.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Hi Mister B, nurse tells me you had a fall?
Patient: Yes, a pretty bad one.
Doctor: Okay, tell me what happened?
Patient: Well, I was running to catch a taxi and stumbled upon a piece of rock, lost my balance and fell.
Patient: I fell face down and my head hit the sidewalk. The next thing I remember is I am all dazed and people trying to help me.
Doctor: I see, did you lose consciousness after the fall?
Patient: No.
Doctor: So, is your head hurting?
Patient: Only the right forehead where I have the scrape and my chin.
Doctor: Okay, any neck or back pain?
Patient: No.
Doctor: Any stomach pain?
Patient: No.
Doctor: Pain anywhere else, in extremities, hand or leg?
Patient: No.
Doctor: Okay, and how old are you?
Patient: I am forty two.
Doctor: Okay.

assistant: Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk. He denies loss of consciousness but says he was dazed for a while after it happened. He complains of pain over the chin and right forehead where he has abrasions. He denies neck pain, back pain, extremity pain or pain in the abdomen.