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: PASTMEDICALHX

Dialogue:
Doctor: Are you okay?
Patient: Yeah, yeah, I am fine.
Doctor: I am asking this as you look a little pale.
Patient: No I am okay. I have always been healthy my whole life. Just a little fatigued now.
Doctor: Okay that won't be something we can't fix.
Patient: Yeah, but I am okay.
Doctor: Yes, I do not see any issues with your past history.
Patient: As I said, I am healthy.

assistant: Otherwise, reviewed. Fairly healthy.
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: Tell me about the medical issues you had in the past or still do.
Patient: Well, I have asthma, sinus. I also have hives and there is a history of psoriasis.
Doctor: Wow, okay. Any known allergies?
Patient: Nothing that I have known.

assistant: The patient has asthma, sinus, hives, and history of psoriasis. No known drug 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: ASSESSMENT

Dialogue:
Doctor: What brings you in today?
Patient: I have this nasty cough and my nose has been super stuffy.
Doctor: Are you bringing anything up when you cough?
Patient: Not really, no.
Doctor: Are you having any other symptoms, such as chest pain, headaches, nausea, or vomiting?
Patient: No. I did have a slight headache last night but I took Advil and it's since gotten better.
Doctor: Are you taking anything for the cough or stuffy nose?
Patient: Just drinking tea and taking cough drops here and there.
Doctor: Okay. Let's take a look at you. Hm it appears that you have a U R I.

assistant: Upper respiratory infection.
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 feeling today, sir?
Patient: I feel pretty weak right now, but I am doing okay at the moment.
Doctor: I reviewed the chart notes that was sent to me by the nursing home. They also sent me your medical history. You have been going through a lot recently.
Patient: Yes, I have. They moved me into the nursing home after I was released from the hospital. I hope that it is just temporary.
Doctor: I understand that you had a seizer and that is why you were taken to the hospital.
Patient: I had multiple seizures. After I was stabilized from the last seizure this side of my body in not working right.
Doctor: Okay so you are having some partial weakness on this side?
Patient: Yes. That is why they moved me to the nursing home. I can't stand up. I am too weak. I can't take care of myself. The nurses have to help me do everything.
Doctor: I am going to try to help you get back to doing things on your own.
Patient: After being in the hospital I got an infection in my intestines. They put me on some antibiotic that I have never heard of and a probiotic.
Doctor: Okay. I see here in the chart that you had two surgeries on July sixth.
Patient: Yes, and then I had a radiation treatment too.
Doctor: Oh yes. On August seventh.
Patient: That sounds right.
Doctor: Your surgeries may have been the reason for the C diff.
Patient: What is C diff?
Doctor: It is an infection in the large intestine. It is often caused by overuse of antibiotics, and you have been on them for a while due to the surgeries that you have had. Or it could be from the surgery itself.
Patient: That make since.

assistant: He said he has had two surgeries in 07/06 followed by radiation and then again in 08/07. He then had a problem with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently. He is unable to stand at the moment. He is unable to care for himself. I reviewed the information that was sent down with him from the nursing home which includes his medical history.
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 is your sleep? Are you sleeping well?
Patient: Yes, without any disturbance. I sleep like a log!
Doctor: Good. Any mood swings or did you feel your emotions are out of control?
Patient: Nah, just the normal mood swings around my periods otherwise no problem at all.
Doctor: Any depression like feeling, sudden mood changes or feeling sad or hopeless?
Patient: Nope!
Doctor: Okay.

assistant: PSYCHIATRIC: No history of emotional lability, depression or sleep disturbances.
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: ASSESSMENT

Dialogue:
Doctor: How's he doing today?
Guest_family: I think he might have fifth disease with sinusitis. It's been running rampant at his school.
Doctor: Oh, wow. Let's see what we can do.

assistant: Fifth disease with sinusitis.
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: Help! I need help! I need to see the doctor!
Doctor: Yes, what's wrong? Where's your pain?
Patient: My stomach! It hurts so much! I've never had this type of pain before!
Doctor: When did it start?
Patient: At ten! I don't know. It started hurting out of nowhere. One second I'm driving home and the next thing I know I had to call-
Doctor: Yes?
Patient: The pain is so bad! It's hard for me to even think straight.

assistant: Abdominal 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: ROS

Dialogue:
Doctor: Just want to ask you few routine questions, let me know if any of this is positive.
Patient: Sure, go ahead.
Doctor: Do you have any problems like headache, fever, rash, oral ulcer?
Patient: None.
Doctor: Any problem with vision? Like unable to see or double vision?
Patient: Um no, I can see everything.
Doctor: Okay. Do you get palpitations, like are you aware of your own heart?
Patient: No, nothing like that.
Doctor: How about breathlessness while lying down or do you have to get up in the middle of the night to catch a breath?
Patient: No I don't feel anything like that.
Doctor: That's great. Any diarrhea, constipation, or red blood come out in stool? Or pale stool? Like any change in the color of stool?
Patient: No, it is fine.
Doctor: Okay. Any jaundice recently?
Patient: No. No jaundice.
Doctor: Do you have problems with appetite?
Patient: Yeah, I mean you can say my appetite is decreased.
Doctor: Because of that have you noticed any weight loss?
Patient: Oh no.
Doctor: Okay sounds good.
Patient: Sure.

assistant: No rashes, headache, photophobia, diplopia, or oral ulcers. No palpitations, orthopnea or PND. No diarrhea, constipation, melena, bright red blood per rectum, or pale stool. No jaundice. Decreased appetite, but no weight loss.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Good morning, ma'am. What seems to be the problem with your knee?
Patient: I've had pain in this knee since I tripped on some ice on March tenth two thousand three.
Doctor: How old are you now?
Patient: I'm forty seven.
Doctor: What kind of symptoms have you had since the fall?
Patient: It's hard for me to stand up without significant pain, and it feels like my knee is going to give way.
Doctor: Has this knee given out before?
Patient: It has.
Doctor: Is there any swelling in this knee?
Patient: Yes, I also feel a popping, like when I go up the stairs.
Doctor: What kind of treatments have you had for this knee?
Patient: I've had antiinflammatories and P T, but I didn't respond well at all.
Doctor: Have you had surgery on this knee in the past?
Patient: Yes, but I can't remember the name of the operation.

assistant: The patient is a 47-year-old female who has knee pain since 03/10/03 after falling on ice. The patient states she has had inability to bear significant weight and had swelling, popping, and giving away, failing conservative treatment and underwent an operative procedure.
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're you doing today, sir?
Patient: Uh I'm hanging in there.
Doctor: I see that you've recently celebrated your seventy second birthday.
Patient: Yep. My kids and grandkids threw me a surprise party. It was really nice.
Doctor: Aw surprises are always fun. However, I'm sorry to hear that you're not doing that well today.
Patient: Yeah, me too. The other day, I had a lot of difficulty getting up from my chair because of weakness all over and a lightheadedness I can't seem to explain.
Doctor: Is this new for you?
Patient: Um I mean I've had falling spells several times a month for the past year, but I've always been able to get myself up one way or another.
Doctor: Do you remember losing consciousness during any of those episodes?
Patient: Not that I recall. I've noticed I'm a lot weaker than before so maybe that's why I keep falling more frequently.
Doctor: I see. Do you experience room spinning dizziness at all?
Patient: No. I also forgot to mention that four hours after not being able to get up from my chair, my left hand became numb for about two hours.
Doctor: Are you right or left handed?
Patient: Right handed.
Doctor: And besides what you've mentioned to me so far, no other symptoms of concern?
Patient: No.

assistant: On the day of presentation, this 72 y/o RHM suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. Four hours later he experienced sudden left hand numbness lasting two hours. There were no other associated symptoms except for the generalized weakness and lightheadedness. He denied vertigo. He had been experiencing falling spells without associated LOC up to several times a month for the past year.
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: And where do you live?
Patient: Well, I live in this small town called Fayetteville in Tennessee.
Doctor: Ah, I see. And do you have lot of friends there?
Patient: I have few.
Doctor: Okay, and do you drink?
Patient: No.
Doctor: How about smoking?
Patient: Never did!

assistant: She does not drink or smoke. Lives in Fayetteville, Tennessee.
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 feeling?
Patient: I am feeling better now.
Doctor: What happened last night?
Guest_family: She went out to a party last night. She came home drunk and high.
Doctor: What did you take?
Patient: I took Ecstasy. I only had two drinks.
Doctor: How much Ecstasy did you take?
Patient: I didn't take them all at once. I think I took six tabs.
Doctor: What time did you start taking the tablets?
Patient: We started taking it kind of late. I think it was midnight.
Guest_family: When she came home, she was agitated and physically shaking. She was pacing all over the house. Then she threw up. That is when I got nervous and called nine one one.
Doctor: Mom, did you notice any blood, or any yellow or green color in the vomit?
Guest_family: No.
Doctor: Are you still feeling nauseous?
Patient: No. I feel fine. Well, I feel weird but not nauseous.
Doctor: Are you experiencing any pain at all?
Patient: No.
Doctor: Did you or do you feel depressed?
Patient: No.
Doctor: Do you or have you ever had suicidal thoughts?
Patient: No.
Doctor: Are you seeing or hearing things that are not real?
Patient: No.
Doctor: Do you or have you ever had thoughts of harming yourself?
Patient: No. I was not trying to harm myself or anyone else. I just wanted to have a little fun.
Guest_family: She seems to be back to her usual self now.
Doctor: Just one more question. Prior to last night have you had any recent illnesses or injuries?
Patient: No.

assistant: This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecsasy tablets. The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis. Mother called the EMS service when the patient vomited. On arrival here, the patient states that she no longer has any nausea and that she feels just fine. The patient states she feels wired but has no other problems or complaints. The patient denies any pain. The patient does not have any auditory of visual hallucinations. The patient denies any depression or suicidal ideation. The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself. The patient denies any homicidal ideation. The patient denies any recent illness or recent injuries. The mother states that the daughter appears to be back to her usual self now.
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: Do you have any support system?
Patient: No, I am single.
Doctor: Okay so live alone at home?
Patient: Yes.
Doctor: Do you smoke or drink?
Patient: Nope I do not.

assistant: The patient is single. Living at home. No smoking or 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: FAM/SOCHX

Dialogue:
Doctor: So, are you married?
Patient: No, my wife and I got divorced a while ago. We have three children together, though.
Doctor: Okay, and do you have someone who is managing your case?
Patient: Yes, I have an lawyer handling everything.
Doctor: Do you smoke or drink?
Patient: No, I never really smoke or drink.

assistant: He is a non-cigarette smoker and non-ETOH user. He is divorced. He has three children. He has an attorney.
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: Have you ever had surgery?
Patient: No, not that I can remember.
Doctor: No gallbladder or appendix removal, c sections, or joint replacements?
Patient: Nope, never had anything done.

assistant: 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: GENHX

Dialogue:
Doctor: I just need to confirm a few pieces of information from my nurse before we begin today, sir.
Patient: Sure, no problem, doctor.
Doctor: Great, so it says here that you are forty five years old, and you identify as Caucasian. Is that correct?
Patient: Yes, that's correct.
Doctor: Thank you, so, what seems to be the problem today?
Patient: Well, I have this pain in my right knee, sir.
Doctor: Where is your pain?
Patient: It's right here, on the inside of my right knee.
Doctor: Is there an injury associated with this pain?
Patient: Actually, yeah. I twisted it while I was at work.

assistant: The patient is a 45-year-old Caucasian male presented to the office complaining of right knee pain. He complained of pain on the medial aspect of his right knee after an injury at work, which he twisted his right knee.
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 evening, and welcome to A B C D General Hospital E D.
Patient: Thank you, Doctor, I've really messed up this ankle.
Doctor: Before we begin, how old are you? And which gender do you identify?
Patient: Thank you for asking, Doctor, I'm a fifty year old man.
Doctor: Thank you, what happened?
Patient: I fell off my liner, and I landed right onto my left foot.
Doctor: How far did you fall?
Patient: Um, it was really about ten feet.
Doctor: Oh, yes, I see. I have some good news for you, there's no gross deformity in this ankle.
Patient: What does that mean, exactly?
Doctor: I don't see any ankle dislocation, which is good.
Patient: Oh, that's good news.
Doctor: Have you had your x rays taken yet?
Patient: Yeah, the tech just brought me back.
Doctor: Great, let me pull them up here. Okay, um, if you look here, you'll see a fracture of your talus.
Patient: Which bone is that?
Doctor: That's your heel, to be specific, it's a grade I V Hawkins fracture of the left talus. You are still neurovascularly intact in the distal region.
Patient: What are we going to do about this?
Doctor: Do you have any other pain from the fall, aside from the ankle?
Patient: No, the ankle really took all of the weight of the fall.
Doctor: Okay, I think we should do surgery in order to repair this ankle.
Patient: Why is that?
Doctor: There is very weak blood flow to the body of this bone, there's a risk for avascular necrosis, which is bone death.
Patient: Okay, you're right. What are the risks of this infection with this surgery?
Doctor: Overall, the risks of infection are less than one percent. We'll use antibiotics to keep everything clean.
Patient: Will I be asleep for this?
Doctor: Yes, you'll be under anesthesia.
Patient: Okay, yes, um, I'd like to go forward with the surgery.

assistant: This is a 50-year-old male who presented to ABCD General Hospital Emergency Department with complaints of left ankle pain and disfigurement. There was no open injury. The patient fell approximately 10 feet off his liner, landing on his left foot. There was evidence of gross deformity of the ankle. An x-ray was performed in the Emergency Room, which revealed a grade IV Hawkins classification talus fracture. He was distal neurovascularly intact. The patient denied any other complaints besides pain in the ankle. It was for this reason, we elected to undergo the procedure in order to reduce and restore the blood supply to the talus body. Because of its tenuous blood supply, the patient is at risk for avascular necrosis. The patient has agreed to undergo the above-named procedure and consent was obtained. All risks as well as complications were discussed.
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: What medications are you currently taking?
Patient: Augmentin, Detroal LA and lisinopril.

assistant: Augmentin; Detrol LA; lisinopril.
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, miss. How are you doing today?
Patient: I have this massive headache.
Doctor: I see. Do migraines usually run in your family?
Patient: They do. Everyone has it. We've been having it for many years.
Doctor: Oh, wow. I'm looking at your blood reports, and it shows you have high blood sugar. Does diabetes run in your family too?
Patient: Yup. We all eat too much rice for dinner.

assistant: There is family history of migraine and diabetes in her siblings.
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's bringing you in today?
Patient: I've had a terrible toothache. I can't stand the pain anymore. I have never experienced this pain in fifty eight years.
Doctor: Where are you experiencing the most pain? And when did this pain start?
Patient: It started about three weeks ago. It's mostly on the left side of my mouth. Kind of on the lower end. It goes from my jaw all the way up to my left ear.
Doctor: That doesn't sound the least bit comfortable. Let's get you feeling better. Do you think it's related to your tooth?
Patient: No, I don't think so. I'm pretty good at making my dentist appointments, although I haven't been in since this new pain started.
Doctor: I see. When was the last time you visited the dentist?
Patient: About two months ago for a routine clean.
Doctor: Have you noticed any facial swelling since all of this started?
Patient: No, no swelling.
Doctor: Any headaches, throat swelling, sore throat, difficulty swallowing or chewing?
Patient: No.
Doctor: How about any neck pain, swollen lymph nodes, chills, fever, or other symptoms?
Patient: No, thank goodness.

assistant: This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear. Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, but has not seen a dentist since this new toothache began. The patient denies any facial swelling. No headache. No swelling to the throat. No sore throat. No difficulty swallowing liquids or solids. No neck pain. No lymph node swelling. The patient denies any fever or chills. Denies any other problems or complaints.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: How long has your finger been in pain, sir?
Patient: Well, at this point, it's been more than a few months.
Doctor: Have you seen another doctor for this pain?
Patient: Yeah, I saw another guy a little while ago.
Doctor: Do you have the records from the visit?
Patient: Yeah, actually, they're right here.
Doctor: Okay, so I see you have a trigger finger, and a mucous cyst, and this other doctor gave you injections. Is that correct?
Patient: Yes sir.
Doctor: Did the injections help at all?
Patient: No sir, honestly, they did nothing.
Doctor: So, your finger is still locking today?
Patient: Yes sir, the other doctor referred me over here to see if there was anything more we could do. I'd like to try surgery.

assistant: The patient has been followed elsewhere, and we reviewed his records. Essentially, he has had a trigger finger and a mucocyst, and he has had injections. This has been going on for several months. He is now here for active treatment because the injections were not helpful, nonoperative treatment has not worked, and he would like to move forward in order to prevent this from keeping on locking and causing his pain. He is referred over here for evaluation regarding that.
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, I am Doctor James.
Guest_family: Hi Doctor, this is my daughter Miya, and I am Jena.
Doctor: Nice to meet you ladies. So, Miya how old are you?
Patient: I am fifteen.
Doctor: Okay, so tell me what is going on with you?
Patient: Well, I am having a severe headache.
Guest_family: She has been complaining about it for almost six hours now.
Doctor: Oh wow. Can you tell me where exactly the pain is?
Patient: Um, it started from my neck and then moved up to the back of my head.
Doctor: I see. Did you get hurt or bump your head?
Patient: No.
Doctor: Does she have any history of headaches?
Guest_family: No.
Doctor: Okay, any nausea or vomiting?
Patient: I am having nausea, but it's coming and going but no vomiting. Also, I am not able to tolerate light at all.
Doctor: Hm, are you able to see properly though, any change in your vision?
Patient: No.
Doctor: Any fever?
Patient: No.
Guest_family: No, no fever.
Doctor: Okay.

assistant: This is a 15-year-old girl presenting with occipital headache for the last six hours. She denies trauma. She has been intermittently nauseated but has not vomited and has some photophobia. Denies fever or change in vision. She has no past history of headaches.
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: And you said you're right handed, correct?
Patient: Yep. Right handed.
Doctor: Okay, great. I've made note of it in your chart. I have one more question to ask regarding tobacco and alcohol. Do you smoke or drink?
Patient: I don't do either. I can't even think of the last time I took a sip of alcohol.

assistant: The patient is right-handed. She does not smoke and does not 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: CC

Dialogue:
Guest_clinician: What brings him in today?
Doctor: He's here for sepsis and I suspect he may have spontaneous bacterial peritonitis.
Guest_clinician: Let me pull up his chart.

assistant: Sepsis, possible SBP.
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's check your throat. Okay, I don't see any swelling or any mass. Is there any pain when I touch you?
Patient: No pain.
Doctor: I don't feel any kind of lump in your throat. That is a good sign. It looks very flexible and symmetric.

assistant: NECK: Supple and symmetric. There was no thyroid enlargement, and no tenderness, or masses were felt.
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:
Patient: Good afternoon, doctor.
Doctor: Remind me, please, how old are you?
Patient: I'm sixty nine years old, doctor.
Doctor: Thank you, what seems to be the problem today?
Patient: Oh, I've had pain in these knees for years, but it's been getting a lot worse over the last few months.
Doctor: Is the pain messing with your ability to do activities?
Patient: Absolutely, sir, yes it is.
Doctor: What kind of treatments have you had so far?
Patient: Another doctor called it conservative treatment, um, I've taken antiinflammatories and had some injections.
Doctor: Do you remember what kind of injections you've had?
Patient: It was, um, cortisone, and Synvisc.
Doctor: Did these relieve the pain at all?
Patient: Well, it was only a temporary relief. Is there anything else we can do?
Doctor: Well, there is surgery for this.
Patient: What are the risks of infection from the surgery?
Doctor: Historically, it's less than one percent.
Patient: How is this possible?
Doctor: We use prophylactic antibiotics in order to eliminate the risk.
Patient: That's great, I've heard of D V T from the commercials, is there a risk for that?
Doctor: There's a risk, but it's low. Other risks are pulmonary embolism, need for further surgery, and further pain.
Patient: Okay, yes, I'd like to do the surgery.

assistant: This is a 69-year-old male with complaints of bilateral knee pain for several years and increased intensity in the past several months where it has affected his activities of daily living. He attempted conservative treatment, which includes anti-inflammatory medications as well as cortisone and Synvisc. This has only provided him with temporary relief. It is for that reason, he is elected to undergo the above-named procedure. All risks as well as complications were discussed with the patient, which include, but are not limited to infection, deep vein thrombosis, pulmonary embolism, need for further surgery, and further pain. He has agreed to undergo this procedure and a consent was obtained preoperatively.
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's this little guy doing today?
Guest_family: I think he might have another ear infection.
Doctor: Oh, I'm sorry to hear that. Let's have a look see.
Guest_family: He's been telling me over and over again that his left ear is hurting him. He was here on April fourteenth and prescribed Amoxicillin.
Doctor: Did that seem to help?
Guest_family: It did at first, but the pain is back again.
Doctor: Has he been running any fevers?
Guest_family: No, no fevers.
Doctor: He sounds a bit congested.
Guest_family: He is. When he blows his nose, he brings up really thick mucous. This never really went away even with antibiotics. He's also been coughing a fair amount.
Doctor: Is his cough productive?
Guest_family: Yeah.
Doctor: Does it seem to be keeping him up at night? How does the mucous look?
Guest_family: No, I don't think so. It is pretty thick and viscous. The cough isn't constant or anything.
Doctor: And no shortness of breath or wheezing that you've noticed?
Guest_family: No.

assistant: Mom brings the patient in today for possible ear infection. He is complaining of left ear pain today. He was treated on 04/14/2004, with amoxicillin for left otitis and Mom said he did seem to get better but just started complaining of the left ear pain today. He has not had any fever but the congestion has continued to be very thick and purulent. It has never really resolved. He has a loose, productive-sounding cough but not consistently and not keeping him up at night. No wheezing 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: GENHX

Dialogue:
Doctor: How are you feeling today, sir?
Patient: I'm doing much better today, doctor.
Doctor: How is your strength and muscular pain?
Patient: They're both improving.
Doctor: Do you have any other complaints today?
Patient: No, I'm doing quite well, honestly.

assistant: The patient was seen and examined. He feels much better today, improved weakness and decreased muscular pain. No other complaints.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: You have cholesterol issues, right?
Patient: Yes.
Doctor: Okay. I see. Gemfibrozil? That sounds familiar? Do you take that?
Patient: Yes, I think that one. But I am not sure.
Doctor: Okay. Do you remember taking them at all as an outpatient?
Patient: I mean I don't remember.
Doctor: Okay don't worry I can look at your previous records. We do have them.

assistant: The only identified problem in his chart is that he is being treated for hyperlipidemia with gemfibrozil. The patient is unaware and cannot remember what medications he had been taking or whether he had been taking them at all as an outpatient.
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 it looks like you're here today for a noticeable foreign body sensation in your eye.
Patient: Yeah, my left eye. Never had this happen to me in my forty one years.
Doctor: First time for everything I guess! When did you first notice the sensation?
Patient: Um when I was at work this morning. It felt like something was in my eye. I went to the bathroom mirror to check it out, but didn't see anything. I flushed my eyes with water in hopes of it helping with the weird feeling.
Doctor: Okay. Hm, are you experiencing any eye pain, blurred vision, or sensitivity to light?
Patient: The pain has definitely gotten worse since this morning. My vision is fine and bright lights don't seem to be a problem.

assistant: This is the initial clinic visit for a 41-year-old worker who is seen for a foreign body to his left eye. He states that he was doing his normal job when he felt a foreign body sensation. He attempted to flush this at work, but has had persistent pain which has progressively worsened throughout the course of the day. He has no significant blurriness of vision or photophobia.
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: What brings you in today?
Patient: I've had a lot of discomfort in my private area.
Doctor: When did it start?
Patient: It's been going on for about two weeks now.
Doctor: Have you noticed any abnormal discharge?
Patient: Not really, no. But it's been super itchy down there.
Doctor: Any abdominal pain, nausea, vomiting?
Patient: Uh no, but I'm having some pain here.
Doctor: Near your pelvis?
Patient: Yeah.
Doctor: Have you started any new lotions or products?
Patient: No.
Doctor: Have you tried anything for the pain or itching?
Patient: No, not yet. I thought it'd go away on it's own.
Doctor: If it's okay with you, I'd like to do a pelvic exam.
Patient: Fine with me.
Doctor: Have you been sexually active prior to or after noticing these concerns?
Patient: Uh once this past week, but it was pretty painful.
Doctor: I see. You may have an infection, which is why I'd also like to send out samples to the lab. Did you use protection?
Patient: Yeah, I take birth control. But I've been struggling a bit with my mood and I'm wondering if it's because of the new birth control pills.
Doctor: We can look into that as well. Hang tight while I grab the nurse for the pelvic exam.

assistant: 1. Infection. 2. Pelvic pain. 3. Mood swings. 4. Painful sex.
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: Do you have any allergies?
Patient: No, I do not have any allergies.
Doctor: Okay so no medically relevant allergies then. Nothing?
Patient: Nope.

assistant: She has no known medical 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: ALLERGY

Dialogue:
Doctor: Any known allergies?
Patient: Oh yes, I cannot take Sulfa drugs.
Doctor: Let me add that to your record.

assistant: She is allergic to Sulfa.
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: So how are you feeling?
Patient: I am feeling well.
Doctor: Any illness or fever?
Patient: No, nothing like that.
Doctor: Any headache or nausea?
Patient: No.
Doctor: Any vomiting or stomach upset?
Patient: No.
Doctor: Okay, any numbness tingling or loss of sensation in the hand?
Patient: No, not at all.
Doctor: Otherwise feeling well?
Patient: Yeah.

assistant: Otherwise well. No febrile illness. No motor or sensory complaints of any sort or paresthesias in the hand.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Welcome to the clinic. I am Doctor Frank.
Patient: Thank you. It is nice to meet you.
Doctor: What brings you into see me today?
Patient: I think I may have had a stroke.
Doctor: What happened to make you think that you had a stroke?
Patient: This morning, I felt like something in my throat. It was a strange feeling. Then I felt really dizzy. My left hand and jaw felt numb.
Doctor: Did you lose consciousness?
Patient: I don't know. It is a bit confusing. I woke up this morning and I was so disoriented that I thought it was the middle of the night. My hand was numb. I also felt the numbness on the left side of my neck and my face.
Doctor: Did the dizzy episode happen after you woke up this morning?
Patient: Yes. I got dizzy when I tried to get out of bed.
Doctor: Has anything like this happen to you in the past?
Patient: About three weeks ago, I had a dizzy episodes and I ended up falling down.
Doctor: Did you have any other symptoms like you did this morning?
Patient: No.
Doctor: Did you see a doctor after the fall you had three weeks ago?
Patient: I saw Doctor X Y Z. Doctor X Y Z put me on Antivert.
Doctor: Have you had any cold or any other resent illnesses?
Patient: I have not had a cold, but I did have an earache about a day or so ago.
Doctor: Okay. How old are you?
Patient: I am seventy five years young.
Doctor: Fantastic.

assistant: The patient is a 75-year-old female who comes in today with concerns of having a stroke. She states she feels like she has something in her throat. She started with some dizziness this morning and some left hand and left jaw numbness. She said that she apparently had something about three weeks ago where she was dizzy and ended up falling down and she saw Dr. XYZ for that who gave her some Antivert. She said that today though she woke up in the middle of the night and her left hand was numb and she was having numbness on the left side of her face, as well as the left side of her neck. She said she had an earache a day or so ago. She has not had any cold symptoms.
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 mom was healthy all her life. She died of old age. She was eighty nine years old. My dad died of a stroke. He was eighty nine as well.
Doctor: Do you have siblings?
Patient: Yes I had a brother and a sister. My sister died way too young. She was only thirty when she passed away from cancer. My brother lasted until he was seventy four. He had coronary artery disease.

assistant: Mother died age 89 of "old age." Father died age 89 of stroke. Brother, age 74 with CAD, Sister died age 30 of 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: ROS

Dialogue:
Doctor: Any history of heart attack?
Patient: No.
Doctor: Any chest pain, palpitations or shortness of breath on exertion?
Patient: No.
Doctor: How about your blood pressure?
Patient: It's normal.
Doctor: Any swelling?
Patient: No.
Doctor: Any history of irregular heartbeats?
Patient: No.

assistant: CARDIOVASCULAR: Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema. No history of heart attack, no history of arrhythmias, no history of hypertension.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Hi, do you smoke?
Patient: No, sir, I don't.
Doctor: Do you take any drugs?
Patient: No.
Doctor: What about drinks? Do you take alcohol in any form?
Patient: No, none of those.

assistant: Denies 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: DIAGNOSIS

Dialogue:
Doctor: Hi there, so you are here for your follow up?
Patient: Yes, I had a surgical removal of multiple abscesses on my right thigh.
Doctor: Okay, let me quickly check your discharge sheet.
Patient: Sure.
Doctor: It says you had multiple extensive subcutaneous abscesses on your right thigh and there was a massive open wound as well.
Patient: Yes, that sounds about right!
Doctor: Okay, and then they did multiple abscesses excisions on your thigh.
Patient: Yes, on my right thigh.
Doctor: Okay.

assistant: 1. Multiple extensive subcutaneous abscesses, right thigh. 2. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.
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: Hi Gina, how are you?
Patient: I wish, I was in better state but yeah, I am okay.
Doctor: I understand. So, you are here for your follow up post your surgeries, right?
Patient: Yes, I am.
Doctor: Alright, I see you recently had your left breast removed due to cancer.
Patient: Correct.
Doctor: And then you also had your right knee replaced due to arthritis in your kneecap, right?
Patient: Yeah, I had arthritis in my knee bone so I got it replaced.
Doctor: Hm.

assistant: Status post left mastectomy secondary to breast cancer and status post right knee replacement secondary to osteoarthritis.
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. How are you all doing today?
Guest_family: We're doing fine. I'm the mother of my four year old boy.
Doctor: Hello, ma'am. What seems to be the problem?
Gest_family: We just wanted to follow up after my son's E R visit.
Doctor: Oh, no. What happened?
Guest_family: He was playing at the park and thought it was a good idea to jump off the swing. Crazy kid, right?
Doctor: It happens. Live and you learn, as they say. Do you have any information from the E R visit.
Guest_family: I gave it to the nurse. Did you not get it?
Guest_clinician: Sorry. I got really busy, but here is the report.
Doctor: Could you read it to me, please?
Guest_clinician: Of course. So, their son severely injured his left distal humerus. No problems were claimed before the injury. The E R saw him for his deformed elbow.
Doctor: Are there any exams on the report?
Guest_clinician: There is an x ray and physical exam. They both confirmed a closed type three supracondylar fracture of his left distal humerus with severe puckering of the skin anteriorly with major ecchymosis in the same region. He did have a radial pulse palpable
Doctor: Thank you, nurse. Mom, were you there before his surgery?
Guest_family: My husband and I were. My husband rushed from this cultural event he had planned.
Doctor: I see. What do you all identify as?
Guest_family: We identify as white.
Doctor: I see. I'm going to perform a neurological exam on your son now. Hi buddy. Is it fine if I do a quick exam?
Patient: Sure.
Doctor: Thanks. It'll be quick.
Patient: Okay.
Doctor: After doing the exam I see his ulnar, median, and radial nerves are intact. I couldn't do the entire exam because the pain might be too much for him.
Guest_family: Thank you so much for your help.

assistant: This is a 4-year-old white male, apparently dominantly right-handed who suffered a severe injury to his left distal humerus after jumping off of a swing. He apparently had not had previous problems with his left arm. He was seen in the Emergency with a grossly deformed left elbow. His parents' were both present preoperatively. His x-ray exam as well as physical exam was consistent with a closed type-III supracondylar fracture of the left distal humerus with rather severe puckering of the skin anteriorly with significant ecchymosis in the same region. Gross neurologic exam revealed his ulnar, median, and radial nerves to be mostly intact, although a complete exam was impossible. He did have a radial pulse palpable.
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: You had a heart procedure done couple months back right?
Patient: Yes, they had to do a cardioversion on me because of my heart rhythm disorder.
Doctor: Okay.
Patient: And I am taking a blood thinner right now.
Doctor: Yes, I saw, you are on Coumadin. Do you know other medications you are on?
Patient: Yes, I have a list with me. Here, look.
Doctor: Wow! That is great. Thank you for being so thorough.
Patient: Sure.
Doctor: So you are on Pacerone, Zaroxolyn, albuterol inhaler, Neurontin, Lasix, and some other.
Patient: Yes.
Doctor: Do you have diabetes?
Patient: No, I do not.
Doctor: Okay, have you smoked in the past?
Patient: Yes, I have, but I quit some years back.
Doctor: Okay. Have you ever had lung problems?
Patient: No, I have not.
Doctor: Okay. How about your family? Anyone sick?
Patient: No, no one is sick in family.

assistant: He states that he is on Coumadin because he had a cardioversion done two months ago for atrial fibrillation. He also lists some other medications. I do have his medications list. He is on Pacerone, Zaroxolyn, albuterol inhaler, Neurontin, Lasix, and several other medicines. Those are the predominant medicines. He is not a diabetic. The past history otherwise, he has had smoking history, but he quit several years ago and denies any COPD or emphysema. No one else in the family is sick.