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: FAM/SOCHX

Dialogue:
Doctor: Do you smoke or drink?
Patient: Nope, I've never touched a cigarette nor do I plan on ever doing so. Same goes for alcohol.

assistant: She does not drink or 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: Hi there! Welcome to the Neurology clinic, sir.
Patient: Hi! Thank you.
Doctor: What brings you in to the clinic today?
Patient: I was diagnosed with binocular diplopia twenty five years ago but I haven't had much of an issue with it until about a year ago.
Doctor: What did you notice as far as symptoms?
Patient: Suddenly, I started having double vision.
Doctor: Did the double vision happen more than one time?
Patient: It has been happening almost every day off and on through out the day.
Doctor: How long do the episodes last?
Patient: They last for only a few minutes at a time. When I was first diagnosed years ago it happened for a year and then it stopped happening. It was not happening as often as it is now.
Doctor: Did you ever receive any treatment for your binocular diplopia?
Patient: No. It spontaneously resolved and so I didn't need to seek any treatment. Back when all this was happening it had two episodes of a drooping eyelid. I thought I had myasthenia gravis but I was told that that was probably not the case.
Doctor: What eyelid was drooping?
Patient: I don't remember?
Doctor: What is your dominate hand?
Patient: I am right handed.
Doctor: And how old are you?
Patient: I am sixty seven.
Doctor: Involving the double vision, does it become worse when looking at distant objects?
Patient: Yes.
Doctor: When you look at objects off to either side of midline does it become worse?
Patient: Yes. That makes it worse too. When I put my hand over one eye is goes away.
Doctor: Do you have any other symptoms related to the vision issues?
Patient: No.

assistant: This 67 y/oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic. The diplopia began acutely and continued intermittently for one year. During this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. He received no treatment and the diplopia spontaneously resolved. He did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. The diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. It resolves when he covers one eye. It is worse when looking at distant objects and objects off to either side of midline. There are no other symptoms associated with the diplopia.
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 is your son?
Guest_family: He is almost five and a half years old now.
Doctor: What seems to be the problem?
Guest_family: He has a lot of pain about both feet, and if you look at it, it looks like his feet rotate inwards.
Doctor: Okay, let me see, okay, um, he has rocker bottom feet.
Guest_family: Okay.
Doctor: I believe he would benefit from a subtalar arthrodesis, possible autograft, and lengthening of the Achilles. I'll go over the details of that procedure right now.
Guest_family: Can we do the surgery soon?
Doctor: Yes we can. But we'll probably need to do another procedure until his foot matures some more. This is a stabilizing measure.
Guest_family: What are the risks of infection if we do the surgery?
Doctor: Historically, the risk of infection is very low, usually less than one percent.
Guest_family: How do you get the risk so low?
Doctor: We use prophylactic antibiotics to minimize the infection risk.
Guest_family: Will he be able to walk again right after the surgery?
Doctor: No, he'll need to stay off it for a while, we call this nonweightbearing. It will only be for some time after the procedure, it's not permanent.
Guest_family: What are the rest of the risks?
Doctor: The total risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time. I would not worry about these risks, though. The risk is low.
Guest_family: Okay. Let's do the surgery.

assistant: The patient is a 5-year-4-month-old male who presents for evaluation of feet. He has been having significant feet pain with significant planovalgus deformity. The patient was noted to have flexible vertical talus. It was decided that the patient would benefit by subtalar arthrodesis, possible autograft, and Achilles lengthening. This was explained to the mother in detail. This is going to be a stabilizing measure and the patient will probably need additional surgery at a later day when his foot is more mature. Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time. All questions were answered and the mother agreed to the above 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: PASTMEDICALHX

Dialogue:
Doctor: Hi there! Welcome in, sir.
Patient: Hi! Thank you.
Doctor: What is your past medical history?
Patient: No. I don't have any health problems.
Doctor: Do you have a primary care doctor?
Patient: No. I don't have health insurance right now.

assistant: The patient denies any previous past medical history. He currently does not have a primary care physician as he is uninsured.
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: Are you married, ma'am?
Patient: Yes.
Doctor: Do you smoke, use alcohol or use recreational drugs?
Patient: No.

assistant: She is married. She does not smoke, use alcohol or use illicit drugs.
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:
Patient: In the past I was very very fat! Actually, I was morbidly obese. I also had high blood pressure, but after my surgery it got resolved.
Doctor: So, everything is okay now?
Patient: Yeah.

assistant: Significant for hypertension and morbid obesity, now 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: So, you were referred by Doctor X.
Patient: Yeah.
Doctor: According to him, I see no changes or correction to your present illness, right?
Patient: Yeah, I think so.

assistant: As per Dr. X without any changes or corrections.
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 related family history?
Patient: You mean like heart issues in the family?
Doctor: Yeah, something like that.
Patient: My brother died of heart attack. It was sudden everyone was shocked.
Doctor: How old was he?
Patient: He was not that old; he was just in his fifties.

assistant: She states her brother died of an MI suddenly in his 50s.
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: So, tell me what's going on? What brings you to the emergency?
Patient: I felt like my heart will explode. I have never felt palpitations like this. I am feeling so weak.
Doctor: When did it start?
Patient: This afternoon.
Doctor: Hm, so your blood pressure is one ninety five by eighty three and your heart rate is one twenty one which is quite high.
Doctor: We have started you on I V Metoprolol. This will help to bring your heartrate down.
Doctor: And you said you are sixty six?
Patient: Yes.
Guest_family: My mom has stopped taking her medications.
Doctor: I can tell from her reports. Her blood pressure is quite high.
Guest_family: It's been several months since she last took her medicines.
Doctor: Well, that's not good!
Doctor: And does she drink and smoke?
Guest_family: Yes, both.
Doctor: How much do you drink Ma'am? Is it occasional?
Guest_family: She drinks a lot!
Patient: Well, I drink about four to five glasses of wine every day. I drank last night.
Doctor: Well, I think you need to cut down on it.
Patient: I am trying doctor and honestly these are all withdrawal symptoms. I have never felt like this before.
Doctor: Hm, I understand. For now I have put you on five M G of Metoprolol and looks like your blood pressure is under control and your heart rate has come down to seventy.

assistant: This 66-year-old patient has history of hypertension and has not taken medication for several months. She is a smoker and she drinks alcohol regularly. She drinks about 5 glasses of wine every day. Last drink was yesterday evening. This afternoon, the patient felt palpitations and generalized weakness and came to the emergency room. On arrival in the emergency room, the patient's heart rate was 121 and blood pressure was 195/83. The patient received 5 mg of metoprolol IV, after which heart rate was reduced to the 70 and blood pressure was well controlled. On direct questioning, the patient said she had been drinking a lot. She had not had any withdrawal before. Today is the first time she has been close to withdrawal.
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, how are you today?
Patient: I am here for a breast cancer screening.
Doctor: Have you gotten a mammogram before?
Patient: Yes, I have. I also try to keep up with my self examinations every few weeks.
Doctor: That is great. I am happy to see you on top of your preventative healthcare.
Patient: I try to be as careful as I can since my sister had breast cancer.

assistant: Her sister had breast cancer.
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 morning, sir.
Patient: Good morning, doctor.
Doctor: So, what seems to be the problem today, sir?
Patient: Well, I've had toe problems in the past.
Doctor: I see, what about the rest of the lower body, any problems there?
Patient: Actually, yes, I've had left knee issues in the past, too.

assistant: He has had toe problems and left knee pain in the past.
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 a history of any health conditions that I should be aware of, ma'am?
Patient: Um, yeah, I had a mastectomy, and chest tube placement.
Doctor: Oh, wow. Do you have any chronic conditions?
Patient: Yeah, I have chronic A F I B.

assistant: History of mastectomy, chest tube placement, and atrial fibrillation; chronic.
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 have you been handing erectile dysfunction since your last visit, sir?
Patient: Well, I've been taking the Cialis, it's the, um, ten M G version.
Doctor: Have you seen any improvement?
Patient: Yes, I've had some, which is good.
Doctor: Have you had any side effects?
Patient: No, none yet.
Doctor: Good, can you describe your erections for me, sir?
Patient: Well, they're firm now, and I can penetrate again for about ten minutes.
Doctor: Good, are you having any chest pain?
Patient: No sir, I stopped using my nitroglycerin too.
Doctor: Good, are you having any fever or chills?
Patient: No, nothing like that.
Doctor: Are you having any pain with urination, or blood in the urine?
Patient: No, nothing like that, sir, everything is normal.
Doctor: How often do you urinate during the day?
Patient: I go about every three hours or so, I have a good stream and everything.
Doctor: Do you wake up at night to go to the bathroom?
Patient: No, I sleep through the night very well.
Doctor: Good, do you have any other conditions that I should know about?
Patient: Well, I have a history of elevated P S A, and I had a biopsy in June when I had a, um, high grade P I N.
Doctor: Do you know what that P S A value was?
Patient: It was eleven point six.
Doctor: Thank you, I see here on Doctor X's notes that there were two specimens that were too small to evaluate.

assistant: The patient presents today for followup, history of erectile dysfunction, last visit started on Cialis 10 mg. He indicates that he has noticed some mild improvement of his symptoms, with no side effect. On this dose, he is having firm erection, able to penetrate, lasting for about 10 or so minutes. No chest pain, no nitroglycerin usage, no fever, no chills. No dysuria, gross hematuria, fever, chills. Daytime frequency every three hours, nocturia times 0, good stream. He does have a history of elevated PSA and biopsy June of this year was noted for high grade PIN, mid left biopsy, with two specimens being too small to evaluate. PSA 11.6. Dr. X's notes are reviewed.
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: I am afraid, I don't have better news for you, your reports confirm cancer.
Patient: We were suspecting it all along, but now since it is confirmed it's just hard to accept.
Doctor: I am sorry, I totally understand. Do you want some time?
Patient: No, I am okay.
Doctor: Hm, you also have hypertension and diabetes.
Patient: Yeah, that I know.
Doctor: Did you have any chest pain or shortness of breath or uneasiness?
Patient: No, I don't have any heart condition.
Doctor: Okay and no dizziness or loss of consciousness or stroke like symptoms?
Patient: No.
Doctor: Okay. Well, your B M I looks fine, that means you are not overweight.
Patient: Hm.

assistant: Positive for hypertension, diabetes, and cancer. Negative for heart disease, obesity or stroke.
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: Are you married?
Patient: Yes. I am happily living together with my husband and my four kids.
Doctor: Oh, do you smoke?
Patient: Nope.
Doctor: What about alcohol or any other kind of drug use?
Patient: Nope.

assistant: Married, lives with husband, 4 children alive and well. Denied 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: Anyone in the family had any medical issues?
Patient: Oh yes.
Doctor: Can you please elaborate?
Patient: So, my mother's side family had heart issues. My dad's sister had sugar problem.

assistant: There was a history of coronary artery disease and diabetes mellitus in 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: ALLERGY

Dialogue:
Doctor: And you are not allergic to anything right?
Patient: That's right.
Doctor: Any drugs or pollens or anything?
Patient: Nope nothing.
Doctor: Good.

assistant: No known allergies.
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: Has the redness worsened over the last few days?
Guest_clinician: I think so. Her right big toe looks worse to me.
Doctor: Is she otherwise healthy?
Guest_clinician: Um besides her toe and some nasal congestion, she's doing fine.

assistant: She has been having the redness of her right great toe, but also just a chronic nasal congestion and fullness. Review of systems is otherwise 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: PASTSURGICAL

Dialogue:
Doctor: You had a surgery on your breasts?
Patient: Yes, they removed lump from my left breast.
Doctor: Okay, and what other surgeries have you had?
Patient: I do not have a gall bladder, then I had a breast augmentation, I have had heart surgeries three times and they have removed half of my pancreas.
Doctor: Okay.
Patient: And knee surgery too, on the left side.
Doctor: Okay. What type of heart surgery did you have?
Patient: Cardiac ablation.

assistant: Significant for history of lumpectomy on the left breast, breast augmentation surgery, cholecystectomy, cardiac ablation x3, left knee surgery as well as removal of half the pancreas.
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: What happened?
Guest_clinician: She was brought to emergency by her son. Apparently, she is doing fine, no distress. She is alert, and I was able to communicate with her and take her history, she was cooperative and calmy responded to all my questions.
Doctor: Okay, that's good.

assistant: GENERAL: Alert and in no apparent distress, calm, cooperative, and communicative.
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 is your family medical history?
Patient: My family has high blood pressure and diabetes.
Doctor: Do you have any family history of nervous system disorder or disease such as multiple sclerosis, Alzheimer's disease, Parkinson's disease, epilepsy, or stroke?
Patient: No.
Doctor: Do you have any children, miss?
Patient: Yes. I have a son, he was born on October thirty first, two thousand and eight.

assistant: There is a family history of diabetes and hypertension. There is no family history of a neuropathy or other neurological disease. She has one child, a son, born on October 31, 2008.
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 ever had any heart problems in the past?
Patient: I remember I did have something heart related but I don't know what that was. I do not understand any medical terms.
Doctor: Okay that's fine, I completely understand. We will try to look for your past medical history.
Patient: I do have hypertension and diabetes, you know that right?
Doctor: Yes, type two diabetes. Do you know of any other things that you had in the past?
Patient: Yes, four years back I had lung embolism. I also get frequent urine infections.
Doctor: Okay. And I can see on the file that you have high cholesterol and a gastric ulcer too.
Patient: Yes, that's about right.
Doctor: Okay. What surgeries have you had in the past?
Patient: I have had my appendix taken out, then C Section, cataract surgery and hernia repair done in the past.

assistant: She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history. She states that she has underlying history of heart disease but is not able to elaborate to any significant extent. She also has a history of hypertension and type II diabetes but is not currently taking any medication. She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections. Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair.
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: Good afternoon, ma'am.
Patient: Good afternoon, doctor.
Doctor: So, are you married?
Patient: Yes, happily to my husband.
Doctor: That's wonderful, um, what do you do for a living?
Patient: I work as an office manager right now.
Doctor: Do you smoke?
Patient: Yes, I do. I've smoked a pack a day for the last twenty years.
Doctor: Do you drink?
Patient: Actually, yes, I drink daily.
Doctor: How much do you drink every day?
Patient: Well, it varies, but usually about anywhere from three to five drinks a day.
Doctor: Okay, do you do any illicit drugs?
Patient: No, absolutely not.
Doctor: What do you do for exercise?
Patient: Well, I go for walks, and like low impact cardio. But, I do like playing softball with my friends too.
Doctor: Very nice, how often do you exercise?
Patient: I work out a few times a month.

assistant: The patient is married. She is employed as an office manager. She does smoke cigarettes, one pack per day for the last 20 years. She consumes alcohol 3 to 5 drinks daily. She uses no illicit drugs. She exercises monthly mainly walking and low impact aerobics. She also likes to play softball.
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: I'm going to run down a list of symptoms and I'd like you to tell me if you've experienced any.
Patient: Okay.
Doctor: Headache?
Patient: No headaches.
Doctor: Are you coughing at all? And if yes, then are you bringing up any blood with your cough?
Patient: No cough.
Doctor: Any chest pain or shortness of breath that wakes you in the middle of the night?
Patient: Nope.
Doctor: Do you feel short of breath when you move around?
Patient: Nope.
Doctor: Any visual, hearing, or swallowing problems?
Patient: None.
Doctor: And finally any changes to your bowel movements or urinary habits?
Patient: Nope. All normal.

assistant: No headaches. No visual, hearing, or swallowing difficulties. No cough or hemoptysis. No chest pain, PND, orthopnea. No changes in bowel or urinary habits. Otherwise, as stated in HPI.
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. Looks like we are here for a general wellness check?
Patient: Yes, sir. In my seventy eight years on this Earth, I have learned to take my health more seriously. I need to start catching things before they come, not after.
Doctor: I could not agree more. From your last checkup notes, it looks like you had right knee surgery and back surgery about eighteen months ago. How is that going? Any pain?
Patient: Yes, I had a right knee replacement. I am doing great so far. Nothing to complain about. I can do almost anything I desire now. It is such a good lifestyle change from before surgery.
Doctor: What do you do with your new body?
Patient: I travel every chance I get. I just got back from a cruise.
Doctor: I hope to be as agile as you when I get to retirement. Now let's check the other systems. Do you feel any type of chest pain? Any heaviness, tightness or pressure?
Patient: No, nothing like that.
Doctor: How about shortness of breath?
Patient: I only get short of breath when I walk up the stairs.
Doctor: That is decently normal. I get out of breath when walking from floor to floor in this hospital too.
Patient: I thought so. I remember being young and still struggling with stairs.
Doctor: Unfortunately, some things are just with us for life. Do you have any coughing fits or irregular heart beating?
Patient: No.
Doctor: Great! You are getting a clean bill of health from me today. On the notes it says you have Crohn's disease. Are you getting regularly checked for that?
Patient: Yes. Doctor Ferguson takes care of me for that.
Doctor: Excellent. Are you scheduled for a prostate check?
Patient: Yes, I go to Doctor Roszhart.
Doctor: You are wonderfully on top of it. What a breath of fresh air. From all of your travelling, how are your ankles? Have you noticed any swelling?
Patient: Surprisingly, from all the walking I do, I do not have any swelling. After quitting smoking ten years ago I had to get addicted to something else and that was walking and travelling.

assistant: This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago. He has done well with that. He does most of the things that he wants to do. He travels at every chance he has, and he just got back from a cruise. He denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations. He sees Dr. Ferguson. He is known to have Crohn's and he takes care of that for him. He sees Dr. Roszhart for his prostate check. He is a nonsmoker and denies swelling in his ankles.
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: IMMUNIZATIONS

Dialogue:
Doctor: And when did you had your last tetanus shot?
Patient: Um, I don't remember correctly, but it should be in my reports. I did have one sometime back, just don't remember when exactly.
Doctor: Ah, no problem. I see it here in your reports and it's up to date. So that's good.
Patient: Cool.

assistant: Up-to-date.
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 where do you stay?
Patient: I stay nearby in my apartment.
Doctor: Alone?
Patient: No, I stay with my boyfriend.
Doctor: Okay, and do you smoke and drink?
Patient: Both.
Doctor: And how much would say you smoke per day?
Patient: Well, I smoke a lot. Seven to eight packs per day.
Doctor: Oh! And for how many years?
Patient: I don't remember exactly but for many, many years, I have a long history of chain smoking.
Doctor: Hm. And alcohol?
Patient: Same, I drink heavily. I have been drinking for many years.
Doctor: Hm.

assistant: She lives with her boyfriend. The patient has a history of heavy tobacco and alcohol abuse for many years.
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 are you, sir?
Patient: One less than sixty.
Doctor: So, what happened?
Patient: I was visiting my son in Cheyenne, Wyoming, then I on October tenth when I was taking a shower, I felt a pop in my head. I don't know what happened after that.
Guest_family: We thought he was having a long shower that day. Then about one and a half hours later my son suspected something is not right and we went up to check. There we found him unconscious on the shower floor. Our son, he then drove us back to Iowa and since then he is complaining of these headaches and that he's not feeling well. He gets unconscious or falls asleep I don't know but it is happening a lot of the time. We got him to local hospital today in the morning. It is three days after that shower incident.
Doctor: Yeah, his report says he got a hemorrhage, I mean, blood clot in his brain.
Guest_family: Yeah, after that report they transferred us to this hospital.

assistant: 59y/o male experienced a "pop" in his head on 10/10/92 while showering in Cheyenne, Wyoming. He was visiting his son at the time. He was found unconscious on the shower floor 1.5 hours later. His son then drove him Back to Iowa. Since then he has had recurrent headaches and fluctuating level of consciousness, according to his wife. He presented at local hospital this AM, 10/13/92. A HCT there demonstrated a subarachnoid hemorrhage. He was then transferred to UIHC.
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: Is this your first surgery or have you had other surgeries in the past?
Patient: This will be my second. I had a hernia repair back in O ten.

assistant: Hernia repair.
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: Where do you work?
Patient: I work at the Hilton as a head chef.
Doctor: Do you smoke or consume any form of tobacco?
Patient: Nope.
Doctor: Do you drink or have ever used any illegal drug?
Patient: No, none of that.

assistant: Employed cook. Denied ETOH/Tobacco/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: ROS

Dialogue:
Doctor: Where do you feel the most pain?
Patient: I'd have to say at the heels of my feet. I spend a lot of time on my feet at work.
Doctor: I see. What kind of shoes do you normally wear to work?
Patient: Regular tennis shoes.
Doctor: Are they cushioned?
Patient: Eh not really, but they're pretty durable.
Doctor: I'd advise getting an orthotic for your shoes to help with the heel pain and resting your feet when you're home. In the meantime, I'd like for you to see a specialist to make sure nothing else is going on.
Patient: Alright, I'm good with that plan.
Doctor: Are you having any other problems? Joint pain, difficulty walking, nausea, vomiting, or other symptoms?
Patient: No, just heel pain for now.

assistant: Positive findings of the foot that have been recorded. All other systems reviewed were 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: FAM/SOCHX

Dialogue:
Doctor: I'm here to take your social history. So, tell me about yourself.
Patient: I was taking drugs. I tried all the methods, mainly I was using inhalation and I V drugs.
Doctor: Right now, you are on methadone, right?
Patient: Yes. I'm also going to the psychiatry department for my depression and these drug issues.
Doctor: What is your living status?
Patient: I live with my roommate.

assistant: The patient has a history of inhalation on intravenous drug abuse. She is currently on methadone maintenance. She is being followed in Psychiatry for depression and substance abuse issues. She lives with a room-mate.
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: I will ask you a few questions about your family history, sir.
Patient: That's okay.
Doctor: Does anyone in your family ever have any medical problems?
Patient: Both of my parents had diabetes.

assistant: His father and mother had 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: FAM/SOCHX

Dialogue:
Doctor: Are you aware of any medical issues in your family?
Patient: I don't know.
Doctor: What about your paternal family?
Patient: I don't know my father. No idea about his family.
Doctor: What about your mom? Maternal family?
Patient: I have no idea. I'm not in contact with her.

assistant: She did not know her father and was not in contact with her mother.
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, sir. Before we begin, how old are you?
Patient: Good morning, doctor. I'm forty one.
Doctor: Thank you, and how long have you had this left knee pain?
Patient: It's been about two years now.
Doctor: Is there an injury?
Patient: Yeah, I sprained my MCL while playing hockey back then.
Doctor: What kind of symptoms have you had in this knee since then?
Patient: Well, the knee locks up on me, I can't extend it all the way, and it just hurts really bad if I try to.
Doctor: Do you feel any instability?
Patient: No, not at all.

assistant: The patient is a 41-year-old male with left knee pain for approximately two years secondary to hockey injury where he did have a prior MCL sprain. He has had a positive symptomology of locking and pain since then. He had no frank instability to it, however.
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: I see here that you've been feeling more short of breath.
Patient: Yes, for three days now.
Doctor: Is it worse when you exert yourself?
Patient: Um no, not really. I've had a terrible cough along with frequent headaches and chest congestion. I have also had a low fever.
Doctor: Did these symptoms start around the same time?
Patient: I think so.
Doctor: Where does your chest feel most congested? And how would you rate the pain right now? Ten being the worst.
Patient: Both sides. I'd say it's at a three currently.
Doctor: Does it send pain or numbness or tingling down your arms? How about any jaw pain as a result?
Patient: No, but it does get worse whenever I cough.
Doctor: Is this your first time experiencing this type of congestion?
Patient: Oh no. I had something like it about ten months ago.
Doctor: Did that improve on its own?
Patient: It would come and go, but over the past few days it's gotten worse. I am a strong German man so I held out coming to the doctor as long as I could.
Doctor: You are very strong! You are sixty nine though, so I don't think anyone would see it as weak if you came to the doctor more often.

assistant: 69-year-old Caucasian male complaining of difficulty breathing for 3 days. He also states that he has been coughing accompanying with low-grade type fever. He also admits to having intermittent headaches and bilateral chest pain that does not radiate to upper extremities and jaws but worse with coughing. Patient initially had this type of episodes about 10 months ago but has intermittently getting worse since.
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: Are you aware of any medical problems in your family?
Patient: No.
Doctor: Anyone with any heart disease or diabetes?
Patient: No.

assistant: Unremarkable.
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: Besides pain in your left eye, are you having any other problems?
Patient: No.
Doctor: Do you happen to have a history of eye problems?
Patient: None.

assistant: Focal left eye pain without any changes in visual acuity or photophobia. He has no prior ophthalmologic problems. Review of systems for cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine, immunologic systems is 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:
Doctor: How are you feeling today?
Patient: I have a lot of anxiety.
Doctor: Anything else?
Patient: I have a lot of pain in my chest as well.
Doctor: Do you drink?
Patient: Yes, I cannot stop myself. I have tried many times but it's hard to control.

assistant: Anxiety, alcohol abuse, and chest 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: FAM/SOCHX

Dialogue:
Doctor: So, do you smoke?
Patient: No.
Doctor: How about alcohol?
Patient: I drink, but just normal. I don't have any alcohol problem.
Doctor: Okay. So, no history of any drug or alcohol abuse, right?
Patient: No, not at all.
Doctor: Okay.

assistant: He is a nonsmoker. He has been drinking alcohol today, but has no history of alcohol or drug abuse.
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 can I help you?
Patient: I am here for a follow up on my heart rhythm problem. I think it is atrial fibrillation.
Doctor: Oh yes. You are not on Cardizem and your heart rate is up just a little bit today.
Patient: That's right. I misplaced it.
Doctor: Okay. Let me see. What symptoms are you experiencing right now?
Patient: I am feeling very dizzy. I do have some vertigo and lightheadedness.
Doctor: You are on blood thinners, right? That is Coumadin therapy? Or am I wrong here?
Patient: No, you are right but please stop the Coumadin. I am tired of these regular blood draws.
Doctor: See, I understand it is hard to control it. It is difficult to regulate that.
Patient: Yes exactly. That is why I don't want it. Give me something simple.
Doctor: Okay I will investigate it. Are you experiencing any chest pain or shortness of breath?
Patient: Oh no, I am not feeling that.
Doctor: Okay great!
Patient: Actually, I am moving around a little bit better now and my arm does not hurt.
Doctor: How about your back pain?
Patient: Um, it is improving as well.
Doctor: Okay, cool.
Patient: Yeah.

assistant: ABC is in today for a followup of her atrial fibrillation. They have misplaced the Cardizem. She is not on this and her heart rate is up just a little bit today. She does complain of feeling dizziness, some vertigo, some lightheadedness, and has attributed this to the Coumadin therapy. She is very adamant that she wants to stop the Coumadin. She is tired of blood draws. We have had a difficult time getting her regulated. No chest pains. No shortness of breath. She is moving around a little bit better. Her arm does not hurt her. Her back pain is improving as 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: GENHX

Dialogue:
Doctor: Good afternoon, ma'am. Can you confirm your age for me, please?
Patient: Sure, good afternoon, doctor. I'm sixty one years old.
Doctor: Great, what brings you in for a visit today?
Patient: I have some notes here with me, but I have a history of polyarteritis nodosa mononeuritis multiplex.
Doctor: Is this in your legs, or arms?
Patient: Um, it's in my legs.
Doctor: I see here that you have sleep apnea too.
Patient: Yeah, I was involved in an overnight sleep study on C P A P and oxygen.
Doctor: Why did they do this?
Patient: It was in order to determine why I had difficulty falling asleep and staying asleep.
Doctor: Have You had any other treatments?
Patient: Yeah, I had a review done while I was in the hospital about two weeks ago, I have the results right here.
Doctor: Thank you, so, how is your leg pain been managed?
Patient: Um, I take pretty substantial doses of opioids in order to control it.
Doctor: Do you have any swelling?
Patient: Yes, I take Lasix for my leg swelling.
Doctor: How do you sleep with the C P A P?
Patient: I can fall asleep with it, but I usually rip my mask off because I toss and turn.
Doctor: How would you rate your quality of sleep?
Patient: I'd, um, say it's pretty terrible.

assistant: This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep. She returns today to review results of an inpatient study performed approximately two weeks ago. In the meantime, the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex. She also takes Lasix for lower extremity edema. The patient reports that she generally initiates sleep on CPAP, but rips her mask off, tosses and turns throughout the night and has "terrible quality sleep."
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 there, what's going on?
Guest_family: I am her daughter. I brought her to the emergency. She lives in a skilled nursing home. Today, when I went to meet her, I found her with the right side of her face drooping. I immediately rushed her here.
Doctor: Oh, you did the right thing. Ma'am, how are you feeling?
Guest_family: She has dementia, most of the time she doesn't even remember me.
Doctor: Oh, okay.How old is she?
Guest_family: She is eighty three. She also has a history of stroke after which she developed this condition where she knows what she wants to speak but is unable to make the word or sentence.
Doctor: Oh, I see. She has expressive aphasia, correct?
Guest_family: Yes, that.
Doctor: Okay, let me check her. She does have a droop to her right side of the face. Ma'am, do you feel any weakness on the right side of your body?
Guest_family: She says yes.
Doctor: She had her C T scan earlier today and I have the report. It does not show any acute attack or anything.
Guest_family: Okay!
Doctor: But it does show that she has a new onset of a stroke.
Guest_family: Is there anything to worry?
Doctor: I think we need to admit her for observation. We need to monitor her. We will also get her a proper treatment for her urinary infection which is not getting better due to resistance to the oral medicines.
Guest_family: Yeah, sounds good!
Doctor: Yeah, let me talk to the nurse.
Guest_family: Thank you.

assistant: The patient is an 83-year-old lady, a resident of a skilled nursing facility, with past medical history of a stroke and dementia with expressive aphasia, was found today with a right-sided facial droop, and was transferred to the emergency room for further evaluation. While in the emergency room, she was found to having the right-sided upper extremity weakness and right-sided facial droop. The CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident, will be admitted to monitor bed for observation and treatment and also she was recently diagnosed with urinary tract infection, which was resistant to all oral medications.
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, are you translating for the patient today? I am sorry, but I do not speak Spanish.
Guest_family: Yes doctor.
Doctor: My chart says this man is fifty two years old, is all of that correct?
Guest_family: Yes doctor, that's correct.
Doctor: Good, so, what seems to be the problem today?
Guest_family: He hurt himself a while back when he slipped on a grape while he was at the grocery store.
Doctor: Oh no, when was this?
Guest_family: It was on October second two thousand eight.
Doctor: Which knee did he injure?
Guest_family: Doctor, it was his left knee.
Doctor: How has he been treated for this so far?
Guest_family: He went straight to the E D immediately, and then he saw his P C P.
Doctor: What did the P C P recommend?
Guest_family: He only referred him to P T, and gave him a knee brace.

assistant: The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient states that on 10/02/08, the patient fell in a grocery store. He reports slipping on a grape that was on the floor. The patient states he went to the emergency room and then followed up with his primary care physician. The patient was then ultimately referred to Physical Therapy. After receiving a knee brace, history and information was received through a translator as the patient is Spanish speaking only.
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 cigarettes?
Patient: I smoke about three packs in a month.
Doctor: Do you drink alcohol or use recreational drugs?
Patient: No.
Doctor: What do you do for work?
Patient: I am an editorial assistant at the local newspaper.

assistant: editorial assistant at newspaper, 40pk-yr Tobacco, no ETOH/Drugs.