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: ROS

Dialogue:
Doctor: Any fever or chills?
Patient: No.
Doctor: Any headache or body pains?
Patient: No.
Doctor: Any nausea vomiting?
Patient: I had vomiting a few times.
Doctor: Did you observe any blood?
Patient: No.
Doctor: Okay, any diarrhea?
Patient: No, on the contrary I am having constipation every now and then, it's really bothering me now. I feel bloated all the time and don't feel fresh in the morning or throughout the day.
Doctor: Oh, how long have you had this problem?
Patient: Couple of months now.
Doctor: Hm, I see, does it hurt you to pass stool? Did you notice any blood?
Patient: No. I use suppositories.
Doctor: Oh, that's great. You are doing the right thing. In addition to that I will prescribe you some strong laxative you can drink that in morning it should help.
Patient: Okay!
Doctor: Any complains of heart burn or acidity or stomach pain?
Patient: No, not really. I do get this twisty pain in my stomach sometimes which I think is mainly due to my constipation.
Doctor: Yeah, you can get that kind of pain with constipation. Any cough or cold like symptoms? Any cough with sputum?
Patient: No, I feel fine.
Doctor: Okay, basically I don't think you have any stomach ulcer or anything, but we need to treat your constipation because I know it can be really uncomfortable.

assistant: General review of system is significant for difficulty with intermittent constipation, which has been problematic recently. He reports no fever, shaking chills, nothing supportive of GI or GU blood loss, no productive or nonproductive cough.
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: Do you take Diovan, estradiol, Norvasc, Wellbutrin?
Patient: Yes, and the Wellbutrin is an inhaler.
Doctor: Okay so inhaler SR?
Patient: Yes.
Doctor: Do you take oxygen therapy at home?
Patient: Yes.
Doctor: Okay.

assistant: Diovan, estradiol, Norvasc, Wellbutrin SR inhaler, and home O2.
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: How long have you and your husband been married?
Patient: Oh, at this point I don't even know how long its been.
Doctor: I assume you live together?
Patient: Yes, we do.
Doctor: What do you do for a living?
Patient: I'm a school nurse for the School Department. I love working with the children.
Doctor: That's wonderful. Do you drink or smoke?
Patient: No, I don't drink, and I quit smoking cigarettes about twenty five years ago.
Doctor: Good for you.

assistant: The patient is married. She lives with her husband and is employed as a school nurse for the School Department. She had quit smoking cigarettes some 25 years ago and is a nondrinker.
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:
Guest_clinician: Any past surgeries?
Doctor: It looks like she had an appendectomy along with a total abdominal hysterectomy and bilateral salpingo oophorectomy sometime ago.
Guest_clinician: Okay, noted.
Doctor: Oh and it looks like she had a right hip fracture back in O five after a fall.

assistant: Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.
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 other allergies besides Penicillin?
Patient: Um no.
Doctor: I see here that you've previously tolerated Cephalosporins without any problems. Do you remember when you were last prescribed a Penicillin like antibiotic?

assistant: PCN, but has tolerated cephalosporins 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: CC

Dialogue:
Doctor: Where are you having pain?
Patient: My left elbow. I hit it against a railing when I was trying to do a new trick on my skateboard.
Doctor: Did the pain come on gradually?
Patient: Yeah. I even tried icing it, but I think it's only gotten worse.
Doctor: Did you injure any other parts of your body?
Patient: Only my elbow.
Doctor: How long ago did this happen?
Patient: About a week ago.
Doctor: I see. Have you taken anything for it, such as Advil or Tylenol?
Patient: No. I try to deal with the pain as best as I can before resorting to medicine.

assistant: Left elbow 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: Do you drink?
Patient: No, doc.
Doctor: How about smoke?
Patient: That I do.
Doctor: How long have you been smoking?
Patient: I long time.
Doctor: Have you tried to quit or reduce how much you smoke?
Patient: Truly, I have no interest in doing that with my age.
Doctor: I see. I'd recommend you consider nicotine patches because smoking brings with it many health problems.
Patient: Tell me something I don't know.
Doctor: I understand. How about any other drug use?
Patient: I know you're not going to like hearing this, but I'm big on weed. I know, I know, I'm going to regret all of this at some point in time. It's just become a habit that's incredibly hard to break.
Doctor: Okay. I'd rather you smoke weed than cigs. How many packs a year do you think you smoke on average?
Patient: I go through a pack around every two weeks. Let's go with around twenty seven.

assistant: She has a 27 pack year smoking history. She denies any alcohol use. She does have a history of chronic marijuana 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: GYNHX

Dialogue:
Doctor: Welcome to the clinic.
Patient: Thank you.
Doctor: It looks like you were referred to us by Doctor Jones.
Patient: Yes I was.
Doctor: Great! The chart notes that Doctor Jones sent over says you are currently twenty weeks pregnant. Is that correct?
Patient: Yes, I am.
Doctor: Do you have any other children?
Patient: Yes. I have a two year old son.
Doctor: Have you ever had any pregnancies? Including miscarriages or abortions.
Patient: Yes. I had a miscarriage before my son was born.
Doctor: I am so sorry to hear that.
Patient: Thank you.

assistant: G3, P1. She is currently 5 months' pregnant.
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.
Doctor: Who do you have in your family?
Patient: Me, my spouse and three happy kids. One of them is ready to go to college.
Doctor: Are you working?
Patient: Yes and no.
Doctor: What does that mean?
Patient: I was an attorney but retired from my official post two years back. I just couldn't stay back home and do nothing, so I just joined a private company and am working there part time.
Doctor: Sounds great. Do you smoke or drink?
Patient: No.
Doctor: I am guessing no drugs either?
Patient: Correct.

assistant: Married. 3 children who are alive and well. Semi-retired Attorney. Denied h/o tobacco/ETOH/illicit drug use.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: When did you stop smoking?
Patient: About thirty years back.
Doctor: Okay. How about any alcohol or drugs?
Patient: No never.
Guest_family: Mom, please let the doctor know about the time when you had it in the past.
Doctor: Yes, please tell me son.
Guest_family: She used to drink a long time back and used to take a lot of prescription medication.
Patient: Okay. Yes, that.
Doctor: Thank you for that information. How long ago?
Patient: I don't remember maybe more than twenty years.

assistant: The patient used to smoke, but quit approximately 30 years ago. The patient denies any alcohol or drug use although her son reports that she has had a long history of this in the past and the patient has abused prescription medication in the past as well according to her son.
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, ma'am?
Patient: No, not that I can remember, and I have a good memory.
Doctor: Not even a C section when you had your son?
Patient: No, I had all my children naturally.

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: FAM/SOCHX

Dialogue:
Doctor: Do you or have you used tobacco products,sir?
Patient: No. I have never been a smoker.
Doctor: Do you have any history of alcohol or recreational drugs use?
Patient: I have never been a drug user, but I used to drink a little, but it was never a problem. I don't drink any more.
Doctor: What do you do for a living?
Patient: I am retired. I used to be an insurance salesman.

assistant: Retired insurance salesman and denies history of tobacco or illicit drug us. He has no h/o ETOH abuse and does not drink at present.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Good afternoon, sir. My nurse has it written down here that that you're a thirty three year old black male, is that correct?
Patient: Yes, doctor, that's correct.
Doctor: Great, what seems to be the problem today, sir?
Patient: Well, I think I'm having some sexual dysfunction. I was wondering if Cialis would help.
Doctor: What makes you think this, sir?
Patient: Well, I did a quiz online on the Cialis website and I didn't score in the normal range, so I figured I would come in.
Doctor: Is there anything else of note, sir?
Patient: Well, there may be some decreased desire, but honestly, I don't think that's the main problem here. I'd like to have my erections last longer, doctor.
Doctor: What was this quiz like?
Patient: Well, on the quiz, I said that less than half of the time I'm able to get an erection and keep an erection after penetration.
Doctor: Are you having difficulty maintaining an erection until completion?
Patient: Well, I'd say there's slight difficulty.
Doctor: Okay, do you have any significant medical conditions in the past that you have been treated for?
Patient: No, not that I know of.
Doctor: What about testicular infections?
Patient: No, that sounds painful, but no.
Doctor: Have you had any traumatic injuries to the groin?
Patient: No, not that I can remember.
Doctor: What about hernias? You can get them from playing sports or lifting weights. Have you ever had one of these?
Patient: No, that doesn't sound familiar either.

assistant: The patient is a 33-year-old black male who comes in to the office today main complaint of sexual dysfunction. Patient reports that he would like to try Cialis to see if it will improve his erectile performance. Patient states that he did a quiz on-line at the Cialis web site and did not score in the normal range, so he thought he should come in. Patient states that perhaps his desire has been slightly decreased, but that has not been the primary problem. In discussing with me directly, patient primarily expresses that he would like to have his erections last longer. However, looking at the quiz as he filled it out, he reported that much less than half the time was he able to get erections during sexual activity and only about half of the time he was able to maintain his erection after penetration. However, he only reports that it is slightly difficult to maintain the erection until completion of intercourse. Patient has no significant past medical history. He has never had any previous testicular infections. He denies any history of injuries to the groin and he has never been told that he has a hernia.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: DIAGNOSIS

Dialogue:
Doctor: We were not able to find the cause of your pain right now, but in the future, we will do a few more tests and then we can have a diagnosis.
Patient: Will you give me some medicine for my stomach pain? And what about that feeling to throw up all of the time?
Doctor: Yes, I will write a prescription. It will help you both with your pain and nausea.

assistant: Nausea and abdominal pain of uncertain etiology.
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: You had a bad acidity problem?
Patient: Yes I was vomiting too.
Doctor: What came out in the vomit?
Patient: It was all brown colored things like coffee.
Doctor: But nothing anymore, right?
Patient: Yes I am all better.
Doctor: Great!
Patient: They told me I can go home.
Doctor: Yes your blood count looks good, I just want you to continue Nexium forty M G once a day.
Patient: I will do that.

assistant: Coffee-ground emesis secondary to severe gastritis, resolved and stable. Hemoglobin at the time of discharge was stable and the patient to continue on Nexium 40 mg once daily.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ROS

Dialogue:
Doctor: How long have you been feeling weakness and fatigue?
Patient: Well, I'd say it's been a lot worse this week. I haven't had much of an appetite either.
Doctor: Have you lost weight as a result?
Patient: I've lost about eight pounds, which is the most I've ever lost in a week's time.
Doctor: Wow, that's concerning. Are you experiencing any nausea, vomiting, diarrhea, or abdominal pain?
Patient: No.
Doctor: How about chest pain, shortness of breath, cough, or heart racing?
Patient: No.
Doctor: Any neurological symptoms, such as numbness or tingling?
Patient: No.
Doctor: We'll get to the bottom of this. I'm waiting for your lab report to come back and then we can figure out the next steps.

assistant: The patient complains of feeling weak and fatigued. He has no appetite over the past week and has lost 8 pounds during this period. No chest pain, palpitations, shortness of breath or coughing. He denies any nausea, vomiting, or abdominal pain. No focal neuro deficits. 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: So, sir, tell me about your knees, how long have they been bothering you?
Patient: Well, I'm sixty nine years old now, so I'm not as young as I used to be. But, these old knees have been bothering me for a couple years now.
Doctor: What kind of symptoms do you notice in these knees?
Patient: I hear clicking noises, which really bothers me when I'm going up stairs. There's also some stiffness when I try to move them.
Doctor: Were you previously a pretty active guy?
Patient: I absolutely used to be, and had no problems, but now this pain is affecting my daily life and activities.

assistant: The patient is a 69-year-old male who presented to the office complaining of bilateral knee pain for a couple of years. The patient complained of clicking noises and stiffness, which affected his daily activities of living.
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: You smoke or drink?
Patient: Nope, I never did any such thing.
Doctor: Any drugs?
Patient: Never.
Doctor: Are you still working?
Patient: I'm retired. I used to work. I used to work in Morse chain. I also used to deliver newspapers. But now I'm retired, and I enjoy life.
Doctor: Are you married?
Patient: I was happily married. But then my husband died.
Doctor: Do you live alone or with family?
Patient: I live alone. I do have family who lives very close by in the neighborhood. I have a niece who lives with her family in my house on Temple Street.

assistant: She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs. She is retired from Morse Chain and delivering newspapers. She is widowed. She lives alone but has family members who live either on her property or adjacent to it.
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: As far as you know, is there any family history of cancer?
Patient: Yes, actually, my mom told me that someone had cervical cancer.
Doctor: What about heart disease, does that sound familiar?
Patient: Yes, I know someone had heart disease, and another person had heart failure.
Doctor: Good to know, what about the lungs, any history there?
Patient: I know someone had C O P D.
Doctor: Do you know of anyone with dementia or Alzheimer's?
Patient: Yes, my uncle has dementia right now, actually.
Doctor: I'm sorry to hear that, that's a hard disease to see your family go through. What about diabetes, does anyone have that?
Patient: Thank you doctor, it's hard. Yes, my dad has the sugar.

assistant: Remarkable for cervical cancer, heart disease, COPD, dementia, diabetes, and CHF.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Can you give me a quick run down of her medical history?
Guest_family: Sure. It's a bit long, sadly.
Doctor: I'm sorry to hear that.
Guest_family: She was recently diagnosed with dementia. She's also suffered from high blood pressure for some time now.
Doctor: When was she diagnosed with dementia?
Guest_family: Six months ago.
Doctor: Any history of heart disease, diabetes, or stroke?
Guest_family: No, but she's not able to control her bladder well which leads to her having frequent accidents. Oh and she's had back pain for several years along with degenerative changes to her spine. Poor thing. I can't help but feel so bad for her situation. It definitely hasn't been easy.

assistant: Include hypertension, dementia, urinary incontinence, chronic back pain, and degenerative joint disease of the spine. No history of diabetes, stroke or coronary artery disease.
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, there. How are you both doing? What brings you two to the Emergency Department?
Guest_family: Hi, Doctor. We're both doing fine. I brought my daughter in today because she's been feeling sick.
Doctor: I see. Let me ask your daughter a few questions before we start. Hi, ma'am. I understand you feel sick. Before we begin I just want to confirm some information with you. Where is your primary residency?
Patient: My mom can give you the address. I still live with her.
Doctor: Thank you. One last question. Do you smoke?
Patient: Nope. My Mother has forbidden smoking in her home.

assistant: Lives at home, here in the ED with the mother and there is no smoking in the home.
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, sir?
Patient: Yes, I'm lucky to have, and live with my lovely wife.
Doctor: That's very nice. Did you speak with the nurse before I came in here?
Patient: Yes, she was lovely as well, I hope you're paying them well.
Doctor: We take good care of them. They'll be happy to hear that. Let me look, she should have left me some notes, um, yep, these look good, I agree with all of this. This looks good.
Patient: Thank you, Doctor.

assistant: The patient is married and lives with his wife. Nursing notes were reviewed with which I agree.
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. How are you doing, sir?
Patient: Hi. I am doing fine.
Doctor: The nurse told me that you are on disability from work now. What happened?
Patient: I got hurt at work and now I am on disability.
Doctor: What did you do for work? How long ago was your injury?
Patient: I worked on the pipeline. The accident was five years ago.
Doctor: Which condition led to the disability?
Patient: I don't know really. I sent in all the notes for my doctor for evaluation and they approved the disability.
Doctor: Okay. Do you live alone or with family?
Patient: I live with my wife.
Doctor: Are you a smoke or have you ever been?
Patient: I used to smoke. I quit years ago.
Doctor: How long ago did you quit?
Patient: Oh, about twenty years ago.
Doctor: How many years did you smoke? And how much did you smoke?
Patient: Probably twenty years. I was up to two packs a day. I feel way better now.
Doctor: That's great. Any use of alcohol or illicit drugs?
Patient: Nope.
Doctor: What do you do for fun? Do you have any hobbies?
Patient: I don't really do much these days. Work was my hobby.
Doctor: Okay.

assistant: He previously worked with pipeline work, but has been on disability for five years. He is unsure which symptoms led him to go on disability. He has previously smoked about two packs of cigarettes daily for 20 years, but quit about 20 years ago. He denies alcohol or illicit drug use. He lives with his wife. He does not really have any hobbies.
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?
Patient: Overall, pretty good.
Doctor: Any plans for the weekend?
Patient: No, not really. Just dog sitting my friend's golden.
Doctor: Gotcha. That's still nice. We used to have a golden when I was a kid. They're the sweetest dogs.
Patient: They are very sweet.
Doctor: Okay, so you're in for a follow up for your neck and back pain.
Patient: Yessir.
Doctor: Have you been going to pain management?
Patient: Yeah, I go once every week or so.
Doctor: How's your pain now?
Patient: Manageable, I guess.
Doctor: Is the pain still keeping you up at night?
Patient: Not like it used to.
Doctor: Good, great to hear.

assistant: Followup evaluation and management of chronic medical conditions.
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: Yes. I smoke.
Doctor: How much do you smoke per day?
Patient: About a pack or two a day.
Doctor: Do you drink alcohol?
Patient: No. It is very rare that I will have a drink.
Doctor: What is your family medical history?
Patient: Well, I don't know very much about my dad's side of the family but my dad did pass away from renal cancer.
Doctor: I am so sorry for your loss.
Patient: Thank you.
Doctor: What about your mother or siblings? Do they have any health conditions?
Patient: No. They don't have any health problems. That I know of.

assistant: 1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.
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, ma'am, what do you do for a living?
Patient: Actually, I'm retired, I don't work at all anymore.
Doctor: Congratulations on your retirement. Where did you go to college?
Patient: Oh, I didn't go to college, I stopped after high school.
Doctor: That's understandable. Do you have children?
Patient: Yes, my husband and I were blessed with three wonderful children.
Doctor: Fantastic, do they live at home?
Patient: Nope, we got them all out of there. They're all grown now.
Doctor: Do you drink or smoke?
Patient: No, I never had either.
Doctor: What about harder substances?
Patient: No, absolutely not.

assistant: The patient is retired. She is married with three grown children. Has a high school level education. Does not smoke, drink, or utilize any illicit substances.
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: You are five feet four inches.
Patient: Yes.
Doctor: Weight one ninety seven.
Patient: Okay.
Doctor: Your blood pressure is one twenty five over seventy five.
Patient: Okay.

assistant: VITAL SIGNS: Blood pressure is 125/75. His weight is 197 with height 5 feet 4 inches.
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: Never smoked a cigarette a day in my life. As for alcohol, I'll drink socially with friends and family.

assistant: Non-smoker. Social drinker.
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: How's he feeling today?
Guest_family: I think this is the worst he's been feeling all week.
Doctor: I'm sorry to hear that he hasn't been feeling well. What symptoms has he been having?
Guest_family: He's been very congested as of late and seems to be coughing a lot more than usual. He was also running a fever yesterday.
Doctor: I see. What was his temperature?
Guest_family: The thermometer was reading one hundred and one degrees Fahrenheit. Does he need to go to the hospital?
Doctor: Let me evaluate and see what we can do for him today.
Guest_family: Thank you, doctor.
Doctor: I suspect that he has an upper respiratory infection, possible pertussis. Is he still experiencing apnea?

assistant: Upper respiratory illness with apnea, possible pertussis.
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: Okay, let me quickly examine him. Mom do you give the permission? I will quickly check his genitalia. Can you pull his pants down?
Guest_family: Sure, you can check.
Doctor: Well, everything looks fine, his penis and testes are normal shape and size for his age. No fluid accumulation or swelling in the scrotum area, no evidence of herniation there.

assistant: EXTERNAL GENITALIA: Normal for age. Normal penis with bilaterally descended testes that are normal in size, shape, and contour, and without evidence of hernia or hydrocele.
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: We can release you from the hospital today if we have a safe place for you to go. Is there a parent or guardian we can release you to?
Patient: I am in foster care. My foster mom is going out of town on the nineteenth to the twenty third.
Doctor: In that case, we will have to keep you in the hospital until your foster mom returns from her trip.
Patient: Can my mom and grandmother come and visit me here on Thursday? That is the day they usually come to visit me at my foster home.
Doctor: Yes. I think we can make some arrangements to make that happen.

assistant: As mentioned, she is in foster care. Foster mom is actually going to be out of town for a week the 19th through the 23rd, so she will probably be hospitalized in respite care because there are no other foster care situations that can handle the patient. Biological Mom and Grandma do visit on Thursdays for about an hour.
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 family history of lung disease, thromboembolism, pulmonary embolism, stroke, or heart disease.
Patient: No. My parents are healthy with no medical issues.
Doctor: How many children do you have?
Patient: I have five kids.
Doctor: Do your children have any health condition?
Patient: My children are all healthy with no medical problems.

assistant: She reported that her parents were healthy with no known medical problems. She had five healthy children with no medical problems. There was no family history of lung disease, thromboembolism, pulmonary embolism, stroke, or heart disease.
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 know of any medical problems that run in your family?
Patient: I have no idea to be quite honest with you. My parents never shared their medical history with me and neither did their parents with them. I don't think they want any of us to worry.
Doctor: Oh wow, I understand. It can be hard for many people to share intimate details about their health to others, even when it comes to disclosing medical info to their own children. For now, I'll put unknown but please let me know if anything changes.
Patient: Will do. Thanks for understanding.
Doctor: Of course. It's not totally uncommon for people to not know their family history.

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

user: Section: GENHX

Dialogue:
Doctor: Hello again, how are you doing, miss?
Patient: I'm good. Thank you. How about you?
Doctor: All good here too. I know you are an established patient of dermatology here and was last seen in our office on July thirteenth, two thousand and four. I will be asking you a few questions just to check whether the entry in our record is updated or not.
Doctor: How old are you now?
Patient: Twenty nine.
Doctor: Where are you from originally?
Patient: I'm from Vietnam.
Doctor: I am seeing you today as a referral from A B C for reevaluation.
Patient: Yes, for my hand eczema.
Doctor: So, let's see what you have been treated with. Your record here says with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion. Does this sound right to you?
Patient: Yes, that's correct.
Doctor: Are you washing your hands in Cetaphil cleansing lotion?
Patient: Yes, I'm doing all that.
Doctor: What brings you here today?
Patient: I'm having this flaring. My hands are all dry. I have these like cracks in my hands. I have been washing with the soap and the lotions that you prescribed, but still, it is happening. Maybe because of cracks or what, I don't know, but the Cetaphil cleansing lotion, whenever I'm applying that it is causing me a lot of burning pain. I have been wearing gloves though.
Doctor: Are you married?
Patient: Still, a single. I'm not even looking for a husband yet.
Doctor: Are you working somewhere?
Patient: Not currently.

assistant: This is a 29-year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04. She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema. I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion. She comes in today for reevaluation because she is flaring. Her hands are very dry, they are cracked, she has been washing with soap. She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin. She has been wearing some gloves also apparently. The patient is single. She is unemployed.
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 been diagnosed with allergic rhinitis, right? For how many years?
Patient: Um, I would say around four years now. Oh my God it has been so, so many medications that I had to take for this.
Doctor: Yeah, it's hard to control. Are you diabetic?
Patient: No, I don't have any such conditions.
Doctor: So no hypertension or any kidney diseases?
Patient: Nope.
Doctor: Every been diagnosed with tuberculosis, asthma, or lung disease?
Patient: No I have not.

assistant: Allergic rhinitis, which she has had for many years and treated with numerous medications. No history of diabetes, hypertension, or renal disease. No history tuberculosis, asthma, or upper airway disease.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PLAN

Dialogue:
Doctor: Hm how would you describe her diet?
Doctor: Does she eat solid food?
Guest_family: Mostly thin liquids and ground meat.
Doctor: I see.

assistant: Regular with regular consistency with thin liquids and ground meat.
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: Hello there, I am Doctor Nathan.
Patient: Hello.
Doctor: How old are you?
Patient: I am forty eight?
Doctor: Do you get regular periods?
Patient: No, I didn't get any periods for the last year after my surgery.
Doctor: Any hot flashes?
Patient: Yes, it's been happening for the last several months. Sometimes I feel hot even in a fully air conditioned room. Other times I just feel like opening the refrigerator and standing in front of it.
Doctor: Any other symptoms?
Patient: I am also experiencing a lot of mood swings for the last few weeks.
Doctor: Based on all the symptoms my assessment would be mood swings along with postsurgical menopause. That would be the cause for your hot flashes.

assistant: 1. Postsurgical menopause. 2. Mood swings.
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 change in appetite?
Patient: Um, no.
Doctor: Any stomach pain or change in bowel movement?
Patient: No.
Doctor: Any history of bowel issues?
Patient: No, not really.
Doctor: Any hernia problem?
Patient: No.
Doctor: Any history of stomach ulcer?
Patient: No.
Doctor: Did you notice any rectal bleeding?
Patient: No.
Doctor: Any liver issues or jaundice?
Patient: Um, no.
Doctor: Okay.

assistant: GASTROINTESTINAL: No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you drink alcohol?
Patient: Nope! I use to occasionally, very long time ago. But not anymore.
Doctor: Okay and how bout cigarettes? Do you smoke or vape?
Patient: No, none of those.
Doctor: And no drugs and stuff, right? No snorting, I V or anything right?
Patient: Right, I don't do drugs either, never did. Even though pot is legal here, I never ever felt like trying.
Doctor: That's a good thing.
Patient: Yeah.

assistant: 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: EXAM

Dialogue:
Doctor: Let me check your neck, it looks nice and symmetrical. Your thyroid looks normal it is not enlarged.
Doctor: Does it hurt you when I press on your neck?
Patient: No.
Doctor: Neck is nontender.
Doctor: Okay, I don't see any bulging of external jugular vein.
Patient: These medical terms I don't understand.
Doctor: Oh, I am talking about the vein in your neck, it shows no bulging. No abnormal masses present. Can you turn your head from left to right and right to left, any pain in your neck or difficulty turning?
Patient: No.
Doctor: Can you rotate your head clockwise and anti clockwise.
Patient: Sure.
Doctor: Any pain?
Patient: No.
Doctor: Okay, let me just make a note here full range of motion with no pain.

assistant: NECK: Supple and symmetric. No masses. Thyroid midline, non enlarged. No JVD. Neck is nontender. Full range of motion without 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: GENHX

Dialogue:
Doctor: Hello, miss. It looks like you are here for your yearly physical. How is everything going?
Patient: Great, I think. I just got a mammogram and nothing showed up. I still am taking my multivitamin and low dose aspirin.
Doctor: Great to hear. Has there been any changes in drinking and smoking?
Patient: No changes. Check the chart, I answered that last time.
Doctor: Great. Looks like drinking and smoking is off the menu. In regard to the mammogram, do you make sure to do self breast examinations? I believe I showed you how to do this last time.
Patient: No, I do not. I don't see a point if I come and do the mammogram.
Doctor: I highly suggest you start doing so. Sometimes people do not get mammograms for a few years and it is important to make sure nothing is growing.
Patient: Yeah, I know. I am just lazy. Recently it has been hard to do a lot of my selfcare routines. I do not even exercise anymore.

assistant: She is not exercising. She does not do self breast examinations. She has recently had her mammogram and it was unremarkable. She does take her low-dose aspirin daily as well as her multivitamin. She does wear her seatbelt. As previously noted, she does not smoke or drink alcohol.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTSURGICAL

Dialogue:
Doctor: Hello. How are you doing today?
Patient: I want to get surgery on my leg.
Doctor: Have you ever had a surgery.
Patient: I did. Here's a list of them.
Doctor: Looks like you had eye surgery, cataract surgery, and lumbar decompression, correct?
Patient: Yeah. So, what options do I have for surgery?
Doctor: I need to see what the problem is first.

assistant: Eye surgery, cataract surgery and lumbar decompression.
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 you guys, how are you?
Patient: I am good, he is my stepdad.
Guest_family: Hi Doctor, how are you?
Doctor: I am fine, thank you. So, she gets seizures?
Guest_family: Yes.
Doctor: And when did it start?
Guest_family: She was fourteen or thirteen. I think fourteen.
Patient: Dad I was fourteen, when it started.
Doctor: Fourteen, okay. Are you taking anything for it?
Guest_family: Yeah, she is on medication.
Doctor: Anybody else in the family have a similar problem?
Guest_family: No, but her sixteen year old brother suffers from N S V T and he sees a specialist.
Doctor: Okay, any other siblings or family members with medical conditions?
Guest_family: Other kids in the family are doing fine, but her maternal grandma suffers from high blood pressure and diabetes.
Doctor: Okay. Sorry but I must ask this, any recent death in the family in past one year child or adult?
Guest_family: Thankfully no!

assistant: Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently. The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia. The maternal grandmother is notable for hypertension and diabetes. There are no other children in the family who see a specialist or no child death less than 1 year of age.
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: Did you have your vaccines?
Patient: Yeah.
Doctor: Did you skip any?
Patient: No, I had all of them and am up to date with my immunizations.

assistant: Also 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: ROS

Dialogue:
Doctor: Hi, how can I help you, ma'am?
Patient: I have no complaints.
Doctor: Okay but tell me what is going on and we can figure this out.
Patient: Okay so my right hand and left foot was very swollen and very painful, and that's why I came to emergency room.
Doctor: Do you have urine bag?
Patient: Yes, I could not go so they put it in.
Doctor: Yes, it looks like five hundred M L came out. So possible urinary obstruction. Also, they started you on steroids and colchicine. How are you feeling now?
Patient: I am feeling a little better, my pain is improving, and the swelling is getting better.
Doctor: Okay that is good. Any fever and chills?
Patient: No, no fever.
Doctor: Any problem with urination like pain or frequency or blood in urine?
Patient: No but I am not able to empty my bladder well, the pee has decreased a lot, I could not urinate.
Doctor: Okay I will evaluate that. How about any cough, blood in sputum?
Patient: No nothing like that.
Doctor: Any chest pain, or difficulty breathing?
Patient: No pain, I can breathe well.
Doctor: Okay that sounds good.

assistant: The patient denies any complaints, states that the right hand and left foot was very swollen and very painful, and came to emergency room. Also, she could not urinate and states as soon as they put Foley in, 500 mL of urine came out. Also they started her on steroids and colchicine, and the pain is improving and the swelling is getting better. Denies any fever and chills. Denies any dysuria, frequency or hematuria. States that the urine output was decreased considerably, and she could not urinate. Denies any cough, hemoptysis or sputum production. Denies any chest pain, orthopnea or paroxysmal nocturnal dyspnea.
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: Does low blood pressure run in your family?
Patient: No. As far as I know, no one else has it.
Doctor: Okay.

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

user: Section: ROS

Dialogue:
Doctor: Were you ever diagnosed with any kind of cancer in the past?
Patient: No.
Doctor: Did you ever had any rashes? Was there any change in your moles?
Patient: No.
Doctor: Any sudden weight loss history?
Patient: No.
Doctor: How about your energy level how do you feel?
Patient: I feel great, my energy level is quite good.

assistant: ONCOLOGIC: No history of any cancer, change in moles or rashes. No history of weight loss. The patient has a good energy level.
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: I am a diabetic, so I take Insulin.
Doctor: How much Insulin do you take?
Patient: It varies from day to day.

assistant: Insulin (unknown dosage)
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: Anything else that is going on?
Patient: Just some pain in the buttock.
Doctor: Okay.
Patient: I do not have anything else.
Doctor: Okay no fever, nausea, anything of that sort?
Patient: Nope.

assistant: Significant for pain in the buttock. Otherwise negative.