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: GENHX

Dialogue:
Doctor: What do you do in the hospital?
Patient: I work as a phlebotomist and respiratory therapist.
Doctor: Ok, how old are you?
Patient: I am fifty four.
Doctor: You are very young.
Patient: Thank you!
Patient: So, as you remember I was trying to measure blood gas as I was working with a patient and I accidently jammed that needle inside my right hand index finger.
Patient: I am coming for regular screening.
Doctor: Were you wearing gloves?
Patient: Yes, I had gloves and protective clothing.
Doctor: Yes, thank you for that. Did they screen patient?
Patient: Yes, he got negative HIV but positive Hep C.
Doctor: Ok.
Patient: I am scared.

assistant: The patient is a 54-year-old right-handed male who works as a phlebotomist and respiratory therapist at Hospital. The patient states that he was attempting to do a blood gas. He had his finger of the left hand over the pulse and was inserting a needle using the right hand. He did have a protective clothing including use of gloves at the time of the incident. As he advanced the needle, the patient jerked away, this caused him to pull out of the arm and inadvertently pricked the tip of his index finger. The patient was seen and evaluated at the emergency department at the time of incident and had baseline studies drawn, and has been followed by employee health for his injury. The source patient was tested for signs of disease and was found to be negative for HIV, but was found to be a carrier for hepatitis C. The patient has had periodic screening including a blood tests and returns now for his final exam.
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: EDCOURSE

Dialogue:
Doctor: They took some fluid out of your back remember?
Patient: Yes actually.
Doctor: We got the results back for that and it looks like it was clear then it turned bloody.
Patient: They checked my urine and blood too.
Doctor: Yes, they did. I see the orders for urine culture, B M P, C B C, C R P, and blood culture as well.
Patient: I got albuterol nebulizer treatment too.
Doctor: That is good. but did that help you?
Patient: No, it did not.
Doctor: Oh I am sorry.
Patient: It is okay.
Doctor: I see that they gave you some antibiotics in E R?
Patient: Yes, Ampicillin and Cefotaxime.

assistant: In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count. This tap was reported as clear, then turning bloody in nature. The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture. This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status. Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.
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: Tell me about your medical history. Did you have any surgeries? Any medical issues in the past?
Patient: I had my tonsils removed when I was a kid, maybe around eight. I was hospitalized for the heart attack in ninety six. They did some surgery to check how my heart is functioning and then they did a bypass I guess.
Doctor: Do you have some record of those surgeries?
Patient: Oh yes, I got it with me. Here it is.
Doctor: That is awesome. Let me have a look. So, according to this you had L I M A to L A D coronary bypass graft. You also had had three saphenous vein grafts performed.
Patient: Yes I had so many surgeries, it's hard to keep a track of all those complex names. That's why I keep those papers with me all the time if I go to any new doctor.
Doctor: I will add all these surgeries into my record. Thank you.

assistant: He had tonsillectomy at the age of 8. He was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure. He did have LIMA to the LAD and had three saphenous vein grafts performed otherwise.
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 everyone in your family?
Patient: My mom, dad and siblings are good.
Doctor: They are well, that is good. That's what we want.
Patient: Yes.

assistant: Mother, father and siblings were alive and well.
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, what do you do for a living, sir?
Patient: I work at A B C store, doctor.
Doctor: That's great, do you smoke?
Patient: No, I don't smoke at all.
Doctor: How about alcohol? Do you drink?
Patient: I'd say I drink socially, like if I'm at a party, or something.

assistant: Works at ABC. Social alcohol and he does smoke.
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, how are you today?
Patient: Good afternoon, Doctor, my knees are in a lot of pain today.
Doctor: Is the pain equal? Or is one knee worse than the other?
Patient: Um, the left knee hurts more than the right, but there's pretty significant pain with both.
Doctor: Is it interfering with your ability to walk?
Patient: Yes, I can walk like, maybe a half a mile a day, then the pain gets too bad.
Doctor: Are you able to go up and down stairs?
Patient: I have to take them one at a time.
Doctor: I see you have degenerative joint disease of both knees, does that ring any bells?
Patient: Yes, but what does that mean?
Doctor: You have arthritis in both of your knees, sir.
Patient: Ah, yes.
Doctor: Have you had surgery on these knees?
Patient: Um, I had surgery on both of these knees, let me check my notes. It was an, um, arthroscopy.
Doctor: When were these surgeries?
Patient: They were in the nineteen ninety one nineteen ninety two time frame, somewhere in there.
Doctor: How have you managed this since the surgeries?
Patient: I've taken antiinflammatories, had injections, and I've even used narcotics.
Doctor: I see. If those haven't helped, I think you'd be a good candidate for knee replacements.
Patient: Can we do both at the same time?
Doctor: No, let's do the left since that one hurts more. Do you have any other conditions I should know about?
Patient: I've had a lot of back surgeries, I have spinal stenosis.
Doctor: Do you know what surgeries you've had?
Patient: Let me check my notes, um, I've had a spinal decompression and epidural steroids injection.
Doctor: Who has prescribed you narcotics for this pain?
Patient: The pain is so bad, but Doctor X has handled those.

assistant: The patient is a 57-year-old with severe bilateral knee DJD, left greater than right, with significant pain and limitations because of both. He is able to walk approximately a 1/2-mile a day but is limited because of his knees. Stairs are negotiated 1 at a time. His problems with bilateral knee DJD have been well documented. He had arthroscopy in the 1991/199two time frame for both of these. He has been on long-standing conservative course for these including nonsteroidals, narcotics, injections. At this point because of his progressive and persistent limitations he has opted for total joint surgery on the left side. He does have other arthritic complaints including multiple back surgeries for spinal stenosis including decompression and epidural steroids. Significant pain is handled by narcotic medication. His attending physician is Dr. X.
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: Yes.
Doctor: How much?
Patient: Two cigarettes per day.
Doctor: Okay that is not bad, but try quitting.
Patient: Okay.
Doctor: Alcohol?
Patient: No, I don't drink.

assistant: Tobacco use, averages two cigarettes per day. Alcohol use, denies.
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 Ryan, what brings you here today?
Patient: Well, you told me to follow up if my cough doesn't get better. Also, I started having several other issues.
Doctor: Oh really!
Patient: Yeah.
Doctor: Okay, so tell me about your cough, is it getting worse than before?
Patient: It's about the same but not getting better.
Doctor: Hm. And what about your diarrhea and stomach pain?
Patient: No more diarrhea and no pian.
Doctor: Bowel movement?
Patient: Normal.
Doctor: Any pain while peeing? Are you able to empty your bladder completely?
Patient: No pain and no problem emptying my bladder.
Doctor: Okay good. Any nausea or vomiting?
Patient: Nope, but I have developed this weird sore taste in my mouth.
Doctor: Oh okay. How long?
Patient: Since last week.
Doctor: I see. Any loss of appetite?
Patient: No, not really.
Doctor: Okay and what other issues were you talking about?
Patient: Yeah, I am also having some trouble with my eyes, I am able see fine, but it feels kind of funny.
Doctor: Okay.
Patient: And then my back is hurting so much, and last week my right shoulder and neck started to hurt.
Doctor: Did you injure it or had a fall or anything?
Patient: No.
Doctor: Okay.

assistant: The patient is in with several medical problems. He complains his mouth being sore since last week and also some "trouble with my eyes." He states that they feel "funny" but he is seeing okay. He denies any more diarrhea or abdominal pain. Bowels are working okay. He denies nausea or diarrhea. Eating is okay. He is emptying his bladder okay. He denies dysuria. His back is hurting worse. He complains of right shoulder pain and neck pain over the last week but denies any injury. He reports that his cough is about the same.
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, sir, what do you do for a living?
Patient: Right now, I'm working with Chevron as a petroleum engineer.
Doctor: That's fantastic. So, do you drink?
Patient: Um, I'd say I drink socially, like if I'm at a party or something.
Doctor: Sure, me too. Do you smoke?
Patient: No sir, I don't do that.

assistant: He is a petroleum engineer for Chevron. Drinks socially. Does not use tobacco.
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: Is anyone else at home sick?
Patient: No. My husband and daughter seem to be doing okay. They haven't complained of anything yet.

assistant: Noncontributory. No one else at home is sick.
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, how are you doing, ma'am? What brings you here today?
Patient: I'm good, thank you. I'm having this weakness on my left side after the brain, I mean, after they removed my tumor from the brain.
Doctor: Remind me when did you have your surgery for brain tumor?
Patient: It was on October twenty fourth last year.
Doctor: How old are you now?
Patient: I'm sixty four.
Patient: He is my husband, Al.
Doctor: Hi, nice to meet you.
Doctor: Tell me what happened.
Patient: They asked me to go to the physical therapy for all the problems I was having after my brain surgery. I went from November fifth to the fourteenth of last year. I did therapy for around two weeks starting on November fifth. My problems were not solved so I went to the hospital and then they did some tests and they found out something was wrong. They said there is swelling in my brain so they admitted me there and then I had my second surgery.
Doctor: When was the second surgery? When did you get admitted?
Patient: It was on December fifth. I was there in the rehab the whole time and then I was discharged for home one month after my second surgery.
Doctor: Was there any other issue?
Guest_family: Yeah. When she was in the rehab she developed something which they called D V T in her left calf. She did not have any such problem again after that.

assistant: The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. The patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness. The patient was being seen in physical therapy from 11/05/08 to 11/14/08 then she began having complications. The patient reports that she was admitted to Hospital on 12/05/08. At that time, they found massive swelling on the brain and a second surgery was performed. The patient then remained in acute rehab until she was discharged to home on 01/05/09. The patient's husband, Al, is also present and he reports that during rehabilitation the patient did have a DVT in the left calf that has since been resolved.
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: Well, I am looking at your test reports and your blood sugars have been running up and down but nothing to be worried about but yeah, we need to keep monitoring. This morning it was perhaps a bit high at one hundred eighty-eight. Last time it was one hundred fifty and in one report it's around one hundred twenty and in lower teens too which is good. So, tell me how are you feeling?
Patient: Well, I am doing okay. I am getting treated for hemorrhoids. I am also having some constipation from the past few weeks and I have recently developed this cough which is okay as I kind of get it often.
Doctor: Oh boy, that's a lot going on!
Patient: Yeah.
Doctor: So, tell me are your hemorrhoids painful?
Patient: No, it's fine.
Doctor: And are you taking anything for constipation?
Patient: Well, just prune juice.
Doctor: Okay, let me write you an order for a laxative that should help. How bout cough? Any pain in the ribs while coughing?
Patient: Nah, I am not bothered by it.
Doctor: Any headache or nerve pain or body pain?
Patient: Um, no I am fine.
Doctor: Any fall or imbalance problem?
Patient: No.
Doctor: Any agitation or any other issues?
Patient: Well, I am doing okay! Sometimes if I have pain, I take Tylenol and usually it works for me.
Doctor: That's good!
Patient: Yeah.
Doctor: So, you have been seeking psychiatric help from Doctor Hudyncia right?
Patient: Yes.
Doctor: She mentioned in her report that you are responding well to her treatment and that your depression is under control and the medicine is working for you. That's good news. Oh, what medicine has she prescribed? Um let me see here in the report, oh okay, got it! It's Cymbalta.
Patient: Right.
Doctor: And no side effects, right?
Patient: No.
Doctor: And looks like the plan is to treat you for a minimum one year.
Patient: Yeah.
Doctor: Lastly, any breathing issues?
Patient: No.

assistant: Overall, the patient has been doing reasonably well. She is being treated for some hemorrhoids, which are not painful for her. There has been a note that she is constipated. Her blood glucoses have been running reasonably well in the morning, perhaps a bit on the high side with the highest of 188. I see a couple in the 150s. However, I also see one that is in the one teens and a couple in the 120s range. She is not bothered by cough or rib pain. These are complaints, which I often hear about. Today, I reviewed Dr. Hudyncia's note from psychiatry. Depression responded very well to Cymbalta, and the plan is to continue it probably for a minimum of 1 year. She is not having problems with breathing. No neurologic complaints or troubles. Pain is generally well managed just with Tylenol.
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: PLAN

Dialogue:
Doctor: So, you saw Doctor X?
Patient: Yes, seven days back. I went to get my blood work done and then I followed up with Doctor Y.
Doctor: Yes, I will look at C B C diff and C M P profile.
Patient: I will follow up with my oncologist, Doctor Z, for my swellings.
Doctor: Yeah, I couldn't get hold of Doctor Z but here is the phone number. You should book the appointment.
Patient: Okay I will do that.
Doctor: Also, I would like to follow up with your endocrinologist that is Doctor A for adjustments that is needed in your insulin pump.
Patient: And you want me to see my gastro doc too?
Doctor: Yes, please follow up with Doctor B for issues with your J tube.
Patient: Sure thing.
Doctor: Lastly, I want you to see Doctor Y if your condition changes regarding colon cancer.

assistant: The patient was instructed to see Dr. X in approximately five to seven days. She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X. She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer. She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes. We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment. She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.
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: I see here that you were in for afib last month.
Patient: Yep.
Doctor: How're you doing?
Patient: It's all under control for now.
Doctor: That's good to hear. Are you still taking Metoprolol and Premarin?
Patient: Yeah.

assistant: Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.
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 health problems I should note?
Patient: Diabetes.
Doctor: Type one or two?
Patient: Type two.
Doctor: Are you on insulin?
Patient: Yeah. I'm also trying to manage it with exercise.

assistant: Diabetes.
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: Let me examine your leg. Well your x ray looks fine. No defect there, I don't see any mass or swelling. Are you able to walk or use that leg at all?
Patient: Oh yes, I am using it. I have also started going back on my regular walk.
Doctor: Good, so your muscle strength is good, no loss of muscle tone there.
Patient: Yeah.

assistant: MSK: No crepitation, defect, tenderness, masses or swellings. No loss of muscle tone or strength.
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: Hello, how are you?
Patient: Hi Doctor, I am good.
Doctor: So, what is going on with you?
Patient: Well, I am having nausea and I just want to get it checked.
Doctor: Okay.

assistant: Nausea.
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: How long have you had this cough?
Patient: Past three weeks, doc.
Doctor: Are you bringing anything up when you cough?
Patient: Nah.
Doctor: Any shortness of breath or chest pain?
Patient: Nah.
Doctor: How about fevers or chills?
Patient: None of that.

assistant: Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.
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: Let's go over your history.
Patient: Okay.
Doctor: I see that you had an appendectomy.
Patient: Back in the nineteen forties. I also had an ankle resection in nineteen seventy five.
Doctor: Any complications with either surgery?
Patient: Uh nope.
Doctor: I also see that you have a recurring history of pneumonia.
Patient: Yeah. Started around age twenty and stuck with me ever since.
Doctor: How often have you had pneumonia?
Patient: Once every five years or so.
Doctor: Have you ever been hospitalized due to pneumonia?
Patient: Uh I'm usually given antibiotics and then discharged.
Doctor: I see.
Patient: Unfortunately, I've had more episodes in the past year than ever before.
Doctor: Any history of inherited lung disease, bronchiectasis, or other chronic pulmonary cause for repeated pneumonia?
Patient: Not to my knowledge.
Doctor: And you recently saw the urologist, correct?
Patient: Yes. I had a catheter placed for urinary retention. He told me he thinks it's due to an enlarged prostate.
Doctor: Do you have a history of diabetes or other medical problems?
Patient: Uh no. I've lost about eighteen pounds in the last month but other than that everything else seems to be fine.

assistant: 1. Pneumonia. He has had recurrent episodes of pneumonia, which started at approximately age 20. These have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year. He is usually treated with antibiotics and then discharged. There is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia. 2. He has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement. The patient does not have any history of diabetes and does not report any other medical problems. He has lost approximately 18 pounds in the past month. 3. He had an appendectomy in the 1940s. 4. He had an ankle resection in 1975.
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: Hi again! How are you feeling today?
Patient: I am feeling okay.
Doctor: Are you still experiencing any nausea or vomiting?
Patient: No. I feel better now.
Doctor: Have you had any shortness of breath or chest pain?
Patient: No.
Doctor: Any painful or burning urination?
Patient: No.
Doctor: Do you have a history of any seizure disorder?
Patient: No.

assistant: Denies any seizure disorder, chest pain, denies any shortness of breath, denies any dysuria, burning or pain, denies any nausea or vomiting at this time. The patient does have a history of nausea and vomiting, but is doing better.
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: Your son had his circumcision performed here at Children's Hospital, correct?
Guest_family: Yes, doctor.
Doctor: Do you remember the date of that procedure?
Guest_family: Um, it was on September sixteenth two thousand seven.
Doctor: Good, the procedure went well. He had some phimosis, but the operation was quite smooth otherwise.
Guest_family: What's phimosis?
Doctor: That's tightness of the foreskin. It sometimes makes the procedure more difficult, but everything went smoothly.
Guest_family: Oh, that's good to hear.
Doctor: He also had a little bit of bleeding when he woke up in the recovery room, so we had to put in some additional sutures.
Guest_family: Okay, thank you for taking care of him.
Doctor: It's my pleasure. Has he been taking his pain medicine?
Guest_family: He took them for a couple days, but he really seems back to normal now. He doesn't seem to be in any pain.
Doctor: Great, does he have any difficulty urinating?
Guest_family: No, that's normal.
Doctor: Bowel movements? How are they?
Guest_family: That's normal too, doctor.

assistant: The patient had his circumcision performed on 09/16/2007 here at Children's Hospital. The patient had a pretty significant phimosis and his operative course was smooth. He did have a little bit of bleeding when he woke in recovery room, which required placement of some additional sutures, but after that, his recovery has been complete. His mom did note that she had to him a couple of days of oral analgesics, but he seems to be back to normal and pain free now. He is having no difficulty urinating, and his bowel function remains normal.
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: Is this something new? Or have you had it before?
Patient: No doctor, this is new.
Doctor: What exactly are you feeling?
Patient: I feel like my tongue is swollen.
Doctor: Okay. How old are you?
Patient: I am fifty four years old.
Doctor: Okay let me see how we can evaluate that.

assistant: A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.
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: So, I think we need to start you on antibiotics for that ulcer on your right foot and possible osteomyelitis. I will send a prescription to your pharmacy.
Patient: Sure.

assistant: Antibiotic management for a right foot ulcer and possible osteomyelitis.
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: Looks like you have a U T I and I need to give you some antibiotics to treat it.
Patient: Okay.
Doctor: I will write you a prescription for Macrobid. Are you still using the Walgreens pharmacy at Thrashers Corner?
Patient: Yes.
Doctor: Are you taking any other medications?
Patient: Yes, I am taking quite a few. I always carry the list of my medications, let me tell you the names. Yeah, so I take Dilantin for my seizures, Toprol for my high blood pressure and Pravachol for my cholesterol.
Doctor: Pravachol for my cholesterol. Wow, thank you for that, it helps a lot. Let me make a note of it.
Patient: Sure.

assistant: Pravachol, Dilantin, Toprol, and Macrobid.
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: Have you had any operations in the-
Patient: Nope. No surgeries.
Doctor: How about any past injuries or illnesses?
Patient: Nope.

assistant: Otherwise noncontributory. There is no operation, serious illness or 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: MEDICATIONS

Dialogue:
Doctor: Have you taken any medications in the past?
Patient: Do you mean prescription, or over the counter?
Doctor: Either of those.
Patient: Oh, I haven't taken anything in the past.

assistant: None.
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: PLAN

Dialogue:
Doctor: Any changes to your diet?
Patient: I've been following the A D A diet online and maxing out at around eighteen hundred calories per day.
Doctor: How're you feeling since starting this diet?
Patient: A lot better actually. My blood sugar isn't as high as it used to be.

assistant: ADA 1800-calorie diet.
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: Hello! How are you doing?
Patient: I am doing okay.
Doctor: Tell me about your past medical history.
Patient: I was diagnosed with stage three ovarian cancer two years ago. They found a tumor in my upper abdomen. I had surgery and they removed everything. Doctor King is my oncologist.
Doctor: Are you still undergoing treatment?
Patient: Yes.
Doctor: Do you have any other medical conditions?
Patient: Have a heart murmur. It has not been an issue. I also have acid reflux.
Doctor: Do you take medication for the G E R D?
Patient: Yes. I take omeprazole.

assistant: 1. Gastroesophageal reflux disease. 2. Mitral valve prolapse. 3. Stage IIIC papillary serous adenocarcinoma of the ovaries.
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 are your parents doing, sir?
Patient: Well, doctor, I've lost both of them now.
Doctor: I'm so sorry to hear that, sir. How about your brothers?
Patient: Thank you, doctor. Both of my brothers are doing very well.
Doctor: Remind me, please, how old are they?
Patient: One of them is sixty eight, and the other is seventy seven. I'm in the middle.
Doctor: That's great. Do you have any medical conditions that run in your family?
Patient: Well, I'm not sure if it counts, but I had a brother and sister, they were twins, they died at birth.
Doctor: Oh no, thank you for telling me.
Patient: Yes, I thought it would be important.
Doctor: Do you have any children, sir?
Patient: Yes, I have two sons, they're both doing very well.
Doctor: How old are your sons?
Patient: One of them is fifty four, and the other is fifty seven.
Doctor: In addition to the neonatal deaths, do you have any other conditions that I should know about?
Patient: Yeah, um, a lot of my family has diabetes, and a lot of them have had heart attacks as well.

assistant: His parents are deceased. He has two brothers ages 68 and 77 years old, who are healthy. He has siblings, a brother and a sister who were twins who died at birth. He has two sons 54 and 57 years old who are healthy. He describes history of diabetes and heart attack in his 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: FAM/SOCHX

Dialogue:
Doctor: Is there anyone that lives with you at home? You are going to need someone to help you care for your wound.
Patient: My wife lives at home with me. She can help me change my bandages.

assistant: The patient lives with his wife.
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: Hello. Looks like you're having surgery today.
Patient: Yeah, I am. I forgot what the surgery was, but it says it in my report.
Doctor: I'm looking at it right now. Looks like you had a PermCath inserted three times and received peritoneal dialysis

assistant: PermCath insertion times 3 and peritoneal dialysis.
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: So, what is happening with you?
Patient: I had knee replacement for both my knees three years ago and now I am having some pain.
Doctor: Okay and in one or both knees?
Patient: Both.
Doctor: Okay.

assistant: He has had bilateral knee replacement three years ago and experiences some pain in his knees with this.
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: EDCOURSE

Dialogue:
Doctor: Hi!
Patient: Hello!
Doctor: How are you feeling now?
Patient: I am feeling okay.
Doctor: Yeah, looks like your condition is improving.
Patient: Yes, I think so too.

assistant: PROGNOSIS: Improved.
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: DIAGNOSIS

Dialogue:
Doctor: And who are we seeing today?
Guest_family: Hi Doctor, this my son J and that's my wife.
Guest_family_2: Hi there
Doctor: Well, hello young man how are you feeling today?
Guest_family_2: He has been complaining of severe tummy pain and was crying the whole time. We are worried as he is a special child. He has autism.
Doctor: For how long now?
Guest_family_2: Autism?
Doctor: No, I mean when did he start complaining of stomach pain?
Guest_family_2: It started last night.
Doctor: Oh okay, let me check him. Did he have any nausea or vomiting?
Guest_family: Yes, he threw up a lot and is refusing to eat or drink anything.
Doctor: And then he is complaining of tummy pain?
Guest_family_2: Yes.
Doctor: Well, the good part is he is not dehydrated.
Doctor: Any diarrhea?
Guest_family_2: Yes, he went three to four times.
Doctor: Hm, but no blood or anything in the stools or vomit?
Guest_family: No, nothing like that, we did not notice anything.
Doctor: Okay good.
Doctor: Well, let me run some tests but the signs and symptoms sound like he might have a stomach flu, also called as gastroenteritis in medical terms. I will start him on some medicines and hopefully that should help.

assistant: 1. Gastroenteritis. 2. Autism.
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: Hello, nice to meet you, miss. I will be taking care of you today. Before we start, can I get to know you a bit? I like to know who I am treating.
Patient: Hello, nice to meet you. Of course. Um, what can I say? I am a recent widow. My husband passed when we were married for only eight years. I am also retired and loving every minute of it.
Doctor: I am sorry to hear that, but I am glad you are happy after retirement. Do you celebrate your infinite days off with a drink or a cigarette?
Patient: No, I do not smoke. I drink occasionally, but it is very rare.
Doctor: Do you have any children that you spend your time with?
Patient: I have three wonderful children.

assistant: She has no tobacco use. She has rare alcohol use. She has three children and is a widow. Her husband died after they were married only eight years. She is retired.
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: Do you eat three meals a day?
Patient: Yes.
Doctor: Do you think those meals add up to about two thousand calories a day?
Patient: I would say yes.

assistant: The patient eats regular diet and eats 3 meals a 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: MEDICATIONS

Dialogue:
Doctor: Are you still taking Micronase every morning?
Patient: Yes, I take um two point five M G once a day.
Doctor: Great. Continue taking Micronase by mouth every day. As for your infection, I want you to start taking Bactrim twice daily. I'll be prescribing you thirty pills. It'll be Bactrim four hundred M G and eighty M G tablets.

assistant: Micronase 2.5 mg Tab PO QAM #30. Bactrim 400/80 Tab PO BID #30.
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 consume any kind of tobacco?
Patient: No.
Doctor: What about smoking?
Patient: No, I've never done it.
Doctor: Any kind of alcohol consumption?
Patient: Nope.

assistant: She does not smoke or drink alcohol.
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 seems to be the problem today?
Patient: I've been having headaches for a while now.
Doctor: How long have you been having these headaches?
Patient: Um, I had my first one about two months ago.
Doctor: Did you suddenly start having them, or was it more gradual?
Patient: Um, I'd say it was more gradual.
Doctor: Where do you feel your headaches?
Patient: Right here, between my eyes.
Doctor: How would you describe your symptoms?
Patient: I'd say it feels like a pressure sensation.
Doctor: What's the intensity of these headaches?
Patient: Um, they're about moderately severe, I guess.
Doctor: Do these headaches interfere with your ability to do your activities?
Patient: Yes, they do. My regular activities are significantly more difficult now.
Doctor: Do you have any sinus congestion?
Patient: Yeah, I do. I also have some light sensitivity.
Doctor: Are you stressed out at work?
Patient: Yes, I have a very stressful job, doctor.
Doctor: Are you sleeping well?
Patient: Well, no not at all. I even try to have a little drink before bed, and it doesn't help.
Doctor: Do you have any oral symptoms, like vomiting or pain in your jaw?
Patient: No, nothing like that.

assistant: The patient describes the gradual onset of a headache problem. The headache first began 2 months ago. The headaches are located behind both eyes. The pain is characterized as a sensation of pressure. The intensity is moderately severe, making normal activities difficult. Associated symptoms include sinus congestion and photophobia. The headache may be brought on by stress, lack of sleep and alcohol. The patient denies vomiting and jaw pain.
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: Do you have any medical conditions that I should know about?
Patient: No, not that I know of.
Doctor: So, there's no history of depression, or cancer, or high blood pressure?
Patient: No, it's not ringing any bells.

assistant: Negative.
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 am having stomach pain.
Doctor: Hm, any nausea or vomiting?
Patient: Yes, both.

assistant: Abdominal pain, nausea and vomiting.
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: Have you been experiencing any mental difficulties or confusion?
Patient: No.
Doctor: Any hallucinations? Are you seeing hearing thing that is not real?
Patient: No.

assistant: No headaches. No visual, hearing, or swallowing difficulties. No changes in bowel or urinary habits.
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: Good afternoon, which gender do you identify with?
Patient: Good afternoon, doctor, thank you for asking, I identify as a female.
Doctor: Great, thank you. Have you ever had surgery on this knee?
Patient: Yes, I actually had an A C L reconstruction done in March of two thousand eight. Um, it didn't go well, so they did a revision at the end of that year, in December.
Doctor: I see, thank you. What about your upper body? Is there any history of surgery there?
Patient: Actually, yes, I had surgery on my arm when I was six.

assistant: She had an anterior cruciate ligament reconstruction in 03/2008, and subsequently had a revision ACL reconstruction in 12/2008. She has also had arm surgery when she was 6 years old.
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, sir.
Patient: Thank you.
Doctor: What do you do for work?
Patient: I am professor at the college up on the hill.
Doctor: What do you teach?
Patient: I teach history and the bible.
Doctor: Do you drink alcohol or use tobacco products?
Patient: No. I do not partake in either of those activities.
Doctor: Okay.

assistant: Negative for use of alcohol or tobacco. He is a professor at College and teaches history and bible.
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: Do you have any major medical conditions that I should know about?
Patient: Yeah, I have a history of thyroid problems, actually.
Doctor: I'm seeing here that you have a history of allergies too, is that correct?
Patient: Oh yes, that's right too.

assistant: Past medical history is significant for allergies and thyroid problems.
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: Tell me about your past problems.
Patient: Sure. I just came into the hospital I think about three weeks back for recurrent urine infections.
Doctor: Yes it says here that you have bladder problems from a long time, mostly related to tone and capacity.
Patient: Yes that is why they put catheter in me.
Doctor: Okay and you have recently had right side C V A?
Patient: Yes, because of my heart problems they had to put pacemaker in.
Doctor: Okay. Good.
Patient: I have hereditary diabetes.
Doctor: Okay and your neural problem is associated to that as well.
Patient: That's right.
Doctor: You have pain on the right side now?
Patient: Yes, because of my stroke.
Doctor: And you take thyroid medications too?
Patient: Yes, for my hypothyroidism.
Doctor: Okay.
Patient: Yeah.
Doctor: What surgeries have you had in the past?
Patient: I have had many surgeries. They took out my gall bladder, then colon cancer surgery was in nineteen ninety eight.
Doctor: And now pacemaker placement, right?
Patient: Yes, that is correct.

assistant: Significant for recurrent UTIs as she was recently to the hospital about 3 weeks ago for urinary tract infection. She has chronic incontinence and bladder atony, for which eventually it was decided for the care of the patient to put a Foley catheter and leave it in place. She has had right-sided CVA. She has had atrial fibrillation status post pacemaker. She is a type 2 diabetic with significant neuropathy. She has also had significant pain on the right side from her stroke. She has a history of hypothyroidism. Past surgical history is significant for cholecystectomy, colon cancer surgery in 1998. She has had a pacemaker placement.
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 have any major medical conditions running in your family history that you know about?
Patient: No, there's nothing of note.
Doctor: So, there's no history of arthritis, or cancer that you're aware of?
Patient: No, not that I know of.

assistant: Noncontributory.
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, does high blood pressure run in your family?
Patient: Um, no it's just me.
Doctor: Okay and this was your first time?
Patient: Yes.
Doctor: Because I am looking at your previous charts and I don't see it mentioned before.
Patient: Oh yeah first time it shot up this high. I never had a high blood pressure problem before.

assistant: Noncontributory to the present condition and review of his previous charts.