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

user: Section: FAM/SOCHX

Dialogue:
Doctor: So, what do you do for a living, sir?
Patient: Right now, I'm a truck driver, sir.
Doctor: Wow, that's hard work. Are you working right now?
Patient: No, I can't right now, I'm on sick leave.
Doctor: Are you married?
Patient: Yes, to my wonderful wife. She's helping to take care of me.
Doctor: Do you two have any children?
Patient: Yes, we have three. We all live together, and for that I'm very thankful.
Doctor: Do you smoke, sir?
Patient: Yeah, I smoke about two packs a day.
Doctor: How about alcohol? Do you drink?
Patient: No, just smoking for me.
Doctor: How about more illicit substances, have you used illegal or prescription drugs inappropriately?
Patient: Oh, absolutely not.
Doctor: That's good. Do you have any other medical conditions that run in your family that I should know about?
Patient: No, not that I know of.

assistant: Occupation: truck driver. Work status: on sick leave. Marital status: married. Children: three. The patient lives at home with family. Tobacco history: smokes two packs of cigarettes per day. The patient denies the use of any alcoholic beverages. The patient denies any current or past history of illegal / recreational drug or prescription drug abuse or addiction. Family History: There are no known significant medical illnesses in the immediate and past family 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: CC

Dialogue:
Doctor: Hello there, how are you?
Patient: I am good, thank you for asking.
Doctor: So, what brings you in today?
Patient: Well, I think I am suffering from memory loss, like short term memory loss.
Doctor: Okay, and why do you say so?
Patient: I have been under tremendous stress for the last five to ten years. I am currently working for T mobile customer service and my work is really hectic. It requires a lot of technical knowledge with project deadlines which is adding to my stress.
Patient: Sometimes I have trouble absorbing all the technical knowledge and computer skills or customer issues.
Doctor: Hm.
Patient: I did my M B A in business for a reason, I wanted to make a good career, but this job is very demanding and stressful. I previously worked at a bank in Conway Springs, Norwich. I have worked many jobs around accounting and management services, but my current job is a high stress one.
Doctor: I see, are you married?
Patient: I have been widowed for past eleven years. My husband died in a car accident, he was hit by drunk driver. It was not the time for my husband to go! After he left, I had to take care of everything and that's another reason for my stress from the past several years.
Doctor: I am so sorry to hear that.
Patient: Yeah.
Doctor: Okay, so tell me any weakness or dizziness or lethargy in the past or now?
Patient: No.
Doctor: Any history of stroke?
Patient: No.

assistant: Here with a concern of possibly issues of short-term memory loss. She is under exceeding amount of stress over the last 5 to 10 years. She has been a widow over the last 11 years. Her husband died in an MVA from a drunk driver accident. She had previously worked at the bank in Conway Springs in Norwich and had several other jobs related to accounting or management services. She does have an MBA in business. Currently, she works at T-Mobile Customer Service, and there is quite a bit of technical knowledge, deadlines, and stress related to that job as well. She feels she has trouble at times absorbing all that she needs to learn as far as the computer skills, protocols, customer service issues, etc. She describes the job is very demanding and high stress. She denies any history of weakness, lethargy, or dizziness. No history of stroke.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: CC

Dialogue:
Doctor: Hi there! Welcome to the clinic.
Patient: Thank you.
Doctor: Doctor Murphy sent your records over. I reviewed the ultrasound, and we did find a kidney stone that has become stuck in the ureter on the left side. The stone is large enough to block the flow of urine from the kidney to the bladder. How much pain are you having and where is the pain located?
Patient: I am in a great deal of pain. It is coming from my left side right here.
Doctor: Okay. Let use discuss your treatment options.
Patient: Okay.

assistant: Left flank pain, ureteral stone.
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 allergies?
Patient: What do you mean?
Doctor: Are you allergic to anything?
Patient: No no, oh no.

assistant: He has no known medicine 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: PASTMEDICALHX

Dialogue:
Doctor: You have type two Diabetes?
Patient: Yes.
Doctor: And High Cholesterol?
Patient: Yes.
Doctor: Your diabetes is poorly controlled.
Patient: I will keep an eye on it.

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

user: Section: GENHX

Dialogue:
Doctor: Can you tell me more about your daughter's injury?
Guest_family: Well, we came in in November, and she was diagnosed with an acute on chronic right slipped capital femoral epiphysis.
Doctor: Did she have surgery on this?
Guest_family: Yes, let me look at my notes, I have it written down here, um, a situ pinning.
Doctor: Remind me, how old are you, dear?
Patient: I'm thirteen now.
Doctor: Okay, thank you. So, um, if you look her at the x rays, it appears that the screw is now going into the hip joint.
Guest_family: They didn't see that before. What can we do about this?
Doctor: We'll need to do another operation in order to remove this screw and put a shorter one in. We need to do the surgery because this can cause further joint damage.
Guest_family: Are there any risks of infection from this surgery?
Doctor: Overall, the risk of infection is very low, honestly its less than one percent.
Guest_family: That's good to hear, will she go to sleep during surgery?
Doctor: Yes, we'll use anesthesia the entire time. She won't feel a thing.
Guest_family: What does recovery look like for this surgery?
Doctor: I expect her to heal up very well, but there's always a risk of some changes in sensation and motion, and she may be stiff for some time following everything. Other risks include bleeding, but I would not worry about these things.
Guest_family: Okay, how does that sound, honey? Would you like to do this?
Patient: Yeah, I want to get back to playing sports with my friends.
Guest_family: I agree, Doctor, we'll do the surgery.

assistant: The patient is a 13-year-old girl who presented in November with an acute on chronic right slipped capital femoral epiphysis. She underwent in situ pinning. The patient on followup; however, noted to have intraarticular protrusion of her screw. This was not noted intraoperatively on previous fluoroscopic views. Given this finding, I explained to the father and especially the mother that this can cause further joint damage and that the screw would need to be exchanged for a shorter one. Risks and benefits of surgery were discussed. Risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, failure to remove the screw, possible continued joint stiffness or damage. All questions were answered and parents agreed to above plan.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: CC

Dialogue:
Doctor: What brings you in today?
Patient: Um a number of different things. I don't even know where to start to be honest.
Doctor: I understand. What's bothering you the most?
Patient: Lemme think. I'm uh having really bad pain.
Doctor: Where's the pain located?
Patient: Hm. It's in a tricky spot.
Guest_family: Hi. Husband here. Let me help explain. She's been having severe lower back pain. It started off mild and got worse over the course of a few days. She's also a lot more sluggish as a result.
Doctor: Any recent injuries or falls?
Guest_family: None. She spends most of her time in bed.

assistant: Severe back pain and sleepiness. The patient is not a good historian and history was obtained from the patient's husband at bedside.
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 want you to meet my assistant. She will be helping me out with your case today.
Doctor: Please represent the patient's case.
Guest_clinician: Patient is a seventy six year old male. He complains of generalized weakness and malaise for several months. He has a two week history of worsening orthostatic dizziness. He denies any recent symptoms of fever or shortness of breath, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes.
Doctor: You said you are feeling dizziness, so what makes it worse?
Patient: It's bad whenever I try to stand straight. I also have these intermittent headaches where it feels like somebody is hammering inside.
Doctor: Do these headaches change with changing the positions or standing straight?
Patient: No.
Doctor: Does the patient have any known medical history?
Guest_clinician: Yes, he has a history of sinusitis.
Doctor: So, your headaches-- how long has this been going on?
Patient: Many weeks now.
Doctor: Do you smoke?
Patient: I used to smoke a hundred and even more packs per year. Now it's just one to two packs each day.
Doctor: Has there been any weight loss?
Patient: I lost forty pounds.

assistant: This 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. The dizziness worsened when moving into upright positions. In addition, he complained of intermittent throbbing holocranial headaches, which did not worsen with positional change, for the past several weeks. He had lost 40 pounds over the past year and denied any recent fever, SOB, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes. He had a 100+ pack-year history of tobacco use and continued to smoke 1 to 2 packs per day. He has a history of 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: ROS

Dialogue:
Doctor: Have you ever had jaundice?
Patient: Um, no.
Doctor: Any rash or anything?
Patient: Nope.

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

user: Section: GENHX

Dialogue:
Doctor: Good morning, ma'am, before we begin, how old are you?
Patient: Good morning, doctor, I'm twenty five.
Doctor: Good, thank you. So, how are you feeling today?
Patient: I'm okay, but I have this rash and itching over my right arm. It's so itchy and I scratch all the time.
Doctor: Is this your dominant hand?
Patient: Yes, so this had especially been bothering me.
Doctor: When did you first notice these symptoms?
Patient: Um, I think it was in October of nineteen ninety two. I think it was the twenty third.
Doctor: Have you had any symptoms in any other parts of your body?
Patient: Um, yeah, I've had tingling in both my legs, like in the front, and then it goes into my toes too.
Doctor: Did this tingling sensation go away?
Patient: Yes, it went away the next day without me doing anything.
Doctor: Have these symptoms returned at any point?
Patient: Well, two days later, so that'd be the twenty fifth, I noticed that my legs felt like they were asleep. I really couldn't feel anything.
Doctor: Have these symptoms spread to any other part of the body?
Patient: Yeah, I couldn't really feel anything in the middle of my chest. I also have started having pain in my right shoulder blade.
Doctor: Do these symptoms interfere with your ability to move?
Patient: Yes, I don't really feel comfortable standing on my own, and I can't walk very well.
Doctor: Do you have any cold or flu like symptoms?
Patient: No, heat and cold don't bother me
Doctor: Do you feel any significant fatigue?
Patient: No, not really.
Doctor: Have you had any significant weight loss?
Patient: No.

assistant: 25y/o RHF began experiencing pruritus in the RUE, above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt "asleep" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, 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: How's it going?
Patient: Good, can't complain.
Doctor: Glad to hear. So today we're going to do a comprehensive eval. It'll be a bit different than our usual visits together. Would you like your mom to step in the room, too?
Patient: Yeah, that's not a problem.
Doctor: Alright. I'll grab her from the waiting room. I'll be right back.

assistant: The patient comes in today for a comprehensive evaluation. She is well-known to me. I have seen her in the past multiple times.
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:
Guest_clinician: I was not able to get her complete history and review of systems. But she is scheduled for a bladder distension surgery.
Doctor: Okay.
Guest_clinician: Also, I am not sure if she is off Coumadin because of the surgery.
Doctor: Oh yeah, she has chronic AFib and she is on Coumadin. Not sure if she has stopped the medicine due to upcoming surgery.
Guest_clinician: The only thing she could tell was that she was having tremors for the past three to four years and was diagnosed with early Parkinson's disease.
Doctor: Alright.

assistant: Complete review of systems is unobtainable at present. From what I can tell, is that she is scheduled for an upcoming bladder distension surgery and I do not know if this is why she is off Coumadin for chronic AFib or what, at this point. Tremor for 3-4 years, diagnosed as early Parkinson's.
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. What is the reason for your visit today?
Patient: I keep having this dry cough and it gets hard to breathe at times.
Doctor: Were you exposed to anything recently?
Patient: Here's a note from a contractor that worked on my house recently. I wasn't sure what it meant.
Doctor: I see. It looks like you may have been exposed to asbestos.
Patient: Oh, no! Am I going to be fine?
Doctor: I'll take a look, but I want to ask you a quick question. Did you have any family living with you at the time?
Patient: Nope. I live alone, so my family wasn't there to be exposed.

assistant: No noted exposures.
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, ma'am?
Patient: Honestly, overall, I'm feeling a lot better.
Doctor: Are you still having the diarrhea and decreased appetite?
Patient: Yes, but I'm still feeling better though.
Doctor: Have you been peeing a normal amount?
Patient: Yeah, no problems there. I measured it like you told me to—six hundred M L.
Doctor: When was the last time you peed?
Patient: Um, it was about seven this morning.
Doctor: Are you having any fever symptoms?
Patient: No, I feel pretty well.

assistant: The patient seen and examined feels better today. Still having diarrhea, decreased appetite. Good urine output 600 mL since 7 o'clock in the morning. Afebrile.
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, sir?
Patient: No.
Doctor: Do you drink?
Patient: No. I was a boxer before so that's why I was always stayed away from these things.
Doctor: How is your living condition? Are you living alone or with family?
Patient: Mostly I'm by myself during the daytime. Family comes to help with me on and off. I just love it that way. I wasn't to be in an independent home setting soon.

assistant: He is a nonsmoker and nondrinker. Prior boxer. He lives in a home where he would need to be independent during the day. Family relatives intermittently available. Goal is to return home to an independent fashion to that home setting.
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.
Doctor: Do you drink alcohol or use recreational drugs?
Patient: Yes, I have been in and out of treatment. I am not doing so well with staying clean.
Doctor: What substances do you use?
Patient: I drink, and I did some coke today. I have been in treatment for heroin and alcohol.

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: GENHX

Dialogue:
Doctor: Hello how are you? Doctor Mina is an intern working with me. She will be taking notes and discussing your case today.
Patient: That's okay.
Doctor: So, tell me Doctor Mina, what brings this young man today here?
Guest_clinician: This is a sixteen year old right handed boy. He is studying in eleventh grade. He is having some difficulties with vision like blurring and focusing. He was diagnosed with a suprasellar tumor. Later on, January fourth, he underwent a surgery for his tumor. Biopsy reports said that it was craniopharyngioma. Even after the surgery, there was some residual disease left and his visual apparatus was decompressed.
Doctor: Thank you Doctor. Tell me how are you doing young man? Are there any difficulties going back to school?
Patient: I am doing fine. I do get some headaches and it feels like somebody is ringing bells in my ears. My eyesight has improved a lot.

assistant: Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor. He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor. Histology returned as craniopharyngioma. There is some residual disease; however, the visual apparatus was decompressed. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Remind me, please, when was your surgery?
Patient: Well, it's been about two and a half months now.
Doctor: Great, we repaired that slipped capital femoral epiphysis on both sides, we call it S C F E.
Patient: Thank you for reminding me, I forgot the names of everything.

assistant: This is a patient post-surgery, 2-1/2 months. The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Is your husband still around, ma'am?
Patient: No, he passed away a few years ago.
Doctor: I'm so sorry to hear that.
Patient: Oh, it's quite all right.
Doctor: Do you drink or smoke?
Patient: No, I don't do either of those.
Doctor: Good, so where are you living now?
Patient: I'm living at Kansas Christian Home.
Doctor: Do you live independently there?
Patient: Yes, thankfully. But, I can't do a lot of things. I have to be sure to take my medicines.
Doctor: Did you drive yourself today?
Patient: No, I had a driver today. Can we speed this up, I need to get to the noon meal.

assistant: The patient is widow. She is a nonsmoker, nondrinker. She lives at Kansas Christian Home independently, but actually does get a lot of help with medications, having a driver to bring her here, and going to the noon meal.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Welcome in, Miss A!
Patient: Thank you.
Doctor: How have you been doing?
Patient: I am good today!
Doctor: Have you not been feeling good other days?
Patient: I have been feeling nervous and having some anxiety lately.
Doctor: Is your feelings of nervousness or anxiousness triggered by anything specific?
Patient: It varies. I feel anxious when I think about retuning to work or this upcoming trip that I have planned.
Doctor: How often do you feel this way?
Patient: It comes and goes.
Doctor: Have you ever had any treatment or history of depression, anxiety, or mood disorders?
Patient: No.

assistant: Ms. A did not report a history of psychological or psychiatric treatment. She reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events. She reported that this only "comes and goes."
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: Who lives with you, miss?
Patient: I live with my boyfriend.
Doctor: Do you smoke cigarettes?
Patient: Yes, I do.
Doctor: How about drugs?
Patient: Sometimes, but I don't want to talk about it.
Doctor: Okay. Anything else you want to talk about?
Patient: Pardon?

assistant: She lives with her boyfriend. The patient has history of tobacco abuse as well as multiple illicit drug abuse.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you have a family history of neurological conditions that I should know about?
Patient: What exactly do you mean by that, doctor?
Doctor: Well, it could be anything from A D H D, to epilepsy, to Alzheimer's.
Patient: Oh, no.

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

user: Section: MEDICATIONS

Dialogue:
Doctor: Are you on any medications?
Patient: Yeah. I take Abilify to help with my mood.
Doctor: Do you find that it's helping?
Patient: A little, yeah.

assistant: Abilify.
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: Your culture results came back positive for Streptococcus pneumoniae. This is a bacterial infection. I would like to take a course of antibiotics. This should start to improve your symptoms with in three to four days.
Patient: Okay.
Doctor: Please let me know if your symptoms have not improved or becomes worse.
Patient: I will. Thank you.

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: PASTMEDICALHX

Dialogue:
Patient: I had a lung transplant in two thousand and four because of Pulmonary Fibrosis.
Doctor: Okay, how are you now? It was, was that for both lungs?
Patient: Yes, both sides.
Doctor: You do have irregular heart rhythm, right?
Patient: Yes, I do.

assistant: Significant for history of pulmonary fibrosis and atrial fibrillation. He is status post bilateral lung transplant back in 2004 because of the pulmonary fibrosis.
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 are you?
Patient: Look at this fifth fingernail on my left hand, doctor.
Doctor: Oh what is stuck here?
Patient: I think it's wood splinter.
Doctor: Oh, must be painful!
Patient: Yes a lot.

assistant: Foreign body of the left fifth fingernail (wooden splinter).
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: Can you move your arms? I would like to see how your range of motion is.
Patient: Sure, see. Like that?
Doctor: Yes, yes, looks good for both arms and legs.
Patient: Great.
Doctor: I do not see any obvious deformities in head neck or in extremities.
Patient: Yes, no problems.
Doctor: Okay?
Patient: Okay.

assistant: MSK: The head and neck by inspection showed no obvious deformity. Again, the extremities showed no obvious deformity. Range of motion appeared to be normal for the upper and lower extremities.
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: Are you allergic to anything?
Patient: Yes, I am allergic to eggs and peanuts.
Doctor: Oh, okay.
Doctor: Anything else? Any medication?
Patient: No, nothing else.
Doctor: Alright.

assistant: Eggs and peanuts.
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, sir?
Patient: No.
Doctor: Do you drink?
Patient: Sometimes I take a beer or two.
Doctor: Are you married?
Patient: For last ten years.
Doctor: What do you do for living?
Patient: I install floor. I am associated with a construction company and my main work is flooring installation.

assistant: He is a nonsmoker. He occasionally has a beer. He is married. He works as a flooring installer.
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, young man. Are these your parents?
Patient: Yes.
Doctor: Good, can you tell me more about your son, please?
Guest_family_1: Well, he's five now, and he fell onto his right arm on December fifth two thousand seven.
Doctor: After he fell, how was he treated?
Guest_family_1: We went to the E D right after he fell, and they said he had complete fractures of both bones in the arm.
Doctor: Yes, I see that here, he also has shortening bayonet apposition.
Guest_family_1: What can we do for this?
Doctor: There's actually a few options here. First we can cast it and see how he heals, generally, children heal up very well from fractures.
Guest_family_1: That's good, we like that option more than any kind of surgery.
Doctor: However, surgery is also an option here as well.
Guest_family_1: Yeah, to be completely sure we fix this, I think we should opt for the surgery, what do you think, honey?
Guest_family_2: Yes, I agree. What are the risks of infection for this surgery?
Doctor: The risk of infection is very low, generally less than one percent. We use antibiotics to control for infection.
Guest_family_1: Will he be asleep for the surgery?
Doctor: Absolutely, he won't feel a thing. Other risks include bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, and cast tightness. I would not worry about these risks. We have great results with these surgeries.
Guest_family_1: Then yes, we'd like to do the surgery.

assistant: The patient is a 5-year-old male who sustained refracture of his right forearm on 12/05/2007. The patient was seen in the emergency room. The patient had a complete fracture of both bones with shortening bayonet apposition. Treatment options were offered to the family including casting versus closed reduction and pinning. The parents opted for the latter. Risks and benefits of surgery were discussed. Risks of surgery included risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, cast tightness. All questions were answered, and the parents agreed to the above plan.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Hello. Are you a new patient?
Patient: I am. I've been traveling a lot, so I don't have a local doctor I usually see.
Doctor: That's fine. What is the reason for your visit?
Patient: I've had this dark spot on my leg for a long time.
Doctor: I see. Do you know if your family has any chronic medical problems?
Patient: Not that I know of.
Doctor: That's good. I think I'll be able to remove it surgically. Before I go over the procedures, have you had a surgery before?
Patient: Yeah, I have. I had surgery on my back and to remove my appendix.
Doctor: Sounds good. Other than that dark spot, you seem to be very healthy.

assistant: Negative for chronic medical problems. No local physician. Has had previous back surgery and appendectomy, otherwise generally 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: PASTSURGICAL

Dialogue:
Doctor: It's surgery day! How are you feeling?
Patient: Not as excited as you.
Doctor: Have you had a surgery before?
Patient: Yeah. It was something with my chest.
Guest_family: Hi Doctor. I'm the mother. He had a chest port placement.
Doctor: I see. Thank you for letting me know.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: What is your living status? Do you live alone or with family?
Patient: I live with my boyfriend.
Doctor: Do you smoke?
Patient: Yes.
Doctor: For how long you are smoking?
Patient: Around ten years.
Doctor: How many cigarettes do you take?
Patient: Well, one pack of cigarettes lasts for around three days.
Doctor: Do you drink?
Patient: I do take beer.
Doctor: How many do you drink a day?
Patient: I take around six bottles once a week.
Doctor: Are you working somewhere?
Patient: I was working in a herbicide plant. There were so many layoffs because of this pandemic. I lost my job too.

assistant: Lives with boyfriend. Smokes one pack of cigarettes every three days and has done so for 10 years. Consumes 6 bottles of beers, one day a week. Unemployed and formerly worked at an herbicide plant.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: I want to talk to you about your reproductive history, okay?
Patient: Okay.
Doctor: Do you take birth control pills?
Patient: Yes, I do.
Doctor: Do you have any kind of medical history that I should be aware of?
Patient: I had both chickenpox and measles when I was a kid.

assistant: Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles.
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 questions.
Patient: Okay shoot.
Doctor: Do you have any nausea, vomiting?
Patient: Yes to both.
Doctor: How about fever?
Patient: Yes, I do.
Doctor: Any blood in sputum or chest pain?
Patient: Yes, I do.

assistant: Ten-system review significant for nausea, vomiting, fever, hemoptysis, and pleuritic chest pain.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you take any tobacco related products?
Patient: I used to chew tobacco, but I quit when I was thirty seven.
Doctor: What about alcohol consumption? Do you drink?
Patient: I take one glass of wine every day.
Doctor: Are you married?
Patient: Yes, sir. I'm married to a wonderful woman for last thirty five years.
Doctor: Are you still working?
Patient: I used to. Now I'm retired, I was a lab manager before.

assistant: He has a history of tobacco use, which he quit at the age of 37. He has one alcoholic drink per day. He is married. He is a retired lab manager.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: CC

Dialogue:
Doctor: Hello! What brings you back into the clinic today?
Patient: I came back because I increased my methothrexate as we discussed the last time I was here. A few days later I started getting multiple canker sores in my mouth. They hurt.
Doctor: I am sorry. It is likely that the increased dosage of your methothrexate is the cause of the mouth sores. Have you experienced a decreased appetite, nausea, abdominal discomfort or diarrhea?
Patient: No. It is painful to eat with the sores, but I still have an appetite.
Doctor: Have you had any new rashes, or hair loss?
Patient: No.
Doctor: I would like to get some bloodwork done. I would also recommend we decrease your dosage back to your previous amount. I would also like to see you back in two weeks to see how you are doing.
Patient: Okay.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are you aware of any medical issues in your family?
Patient: No.
Doctor: How about any known heart disorder or diabetes in the family.
Patient: No, I'm not aware of anything like that.

assistant: Otherwise 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: IMAGING

Dialogue:
Doctor: So, I am looking at his x ray and it does not show any open fracture or any kind of bone abnormality.
Guest_family: Okay, I was really worried about my son.
Doctor: I understand, but like I said, I didn't see any open fracture in his x ray report nor any abnormality.
Guest_family: Okay.

assistant: X-rays shows no open fracture or bony abnormality.
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: Yes, I do take two or four beers in a day.
Doctor: Do you smoke?
Patient: Oh yeah, I'm a smoker. I take around one to two packs of cigarettes each day.

assistant: 2-4 Beers/day. 1-2 packs of cigarettes per day.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you live alone?
Patient: I wouldn't say I live alone. I have three cats and they always keep me company.
Doctor: Aw, what kind of cats?
Patient: Two Persian cats and one Chartreux.
Doctor: Are you currently working?
Patient: I retired a few months ago. I used to work as a psych aide for the State of Pennsylvania.
Doctor: Congratulations on your retirement.
Patient: Thank you.
Doctor: How long did you work as a psych aide?
Patient: Thirty two years.
Doctor: Incredible. One more question. Do you smoke, drink, or use drugs recreationally?
Patient: I drink wine every now and then. I used to smoke back in the day, but I'm five years smoke free. I do not do drugs.
Doctor: Always great to hear.

assistant: The patient lives by herself and has three pet cats. She is an ex-smoker, quit smoking about five years ago. She occasionally drinks a glass of wine. She denies any other recreational drugs use. She recently retired from State of Pennsylvania as a psychiatric aide after 32 years of service.
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: Hi there! What brings you in today?
Guest_family: I think my baby got into the ant bait. I am not sure if he consumed any of it but he was under the counter and it was in his hands.
Doctor: What kind ant bait did he get into?
Guest_family: It was the one with Borax in it.
Doctor: Do you have a picture of it?
Guest_family: Yes. It is in my phone.

assistant: Possible exposure to ant bait.
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. I just need to confirm some information about you before we begin today.
Patient: Good morning, doctor. Sure, that's no problem.
Doctor: Great, so you're sixty seven years old, and White, correct?
Patient: Yes, that's right doctor.
Doctor: Thank you. Do you remember how many cycles of carboplatin and Taxol you've had for your cancer, ma'am?
Patient: Um, I've had six, I'm here for a follow up today.
Doctor: Yes, I see here that your last chemo treatment on January eighteenth two thousand eight.
Patient: Yes, I remember that. Can you remind me the full name of my cancer?
Doctor: It's a uterine papillary serous carcinoma.
Patient: Thank you, doctor.
Doctor: Sure, do you have any problems today?
Patient: Well, I just have some numbness in my right upper arm today.
Doctor: Has this gotten worse recently?
Patient: Well, no, not really.
Doctor: That's good. Do you feel this in your toes at all?
Patient: No, there's no numbness there.
Doctor: Good, do you have any tingling or burning to speak of?
Patient: No, thankfully no.

assistant: The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup. Her last cycle of chemotherapy was finished on 01/18/08, and she complains about some numbness in her right upper extremity. This has not gotten worse recently and there is no numbness in her toes. She denies any tingling or burning.
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 long has she had difficulty swallowing?
Guest_family: A while now. We scheduled her to see an endocrinologist, but she's not able to get in until Monday. I wanted to see if we could get to the bottom of it now.
Doctor: It does appear that her thyroids are fairly enlarged. I believe that's where most of her symptoms, if not all, are stemming from.
Guest_family: Does that mean she'll need surgery?
Doctor: We'll have to see, but chances are higher since she's experiencing symptoms due to her thyroid.
Guest_family: When will we find out?
Doctor: I'd like to get some imaging done and see if we can get a consult in first.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you have any significant medical conditions that run in your family that I should be aware of?
Patient: Yes, um, I know some of my relatives have had coronary artery disease, and, um, high blood pressure.
Doctor: What about cancer? Does anyone in your family have a history of cancer?
Patient: No, that doesn't ring any bells.

assistant: Includes coronary artery disease, hypertension. Nobody in the family was diagnosed with any type of colon cancer or any type of other cancer.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Any past medical problems or surgeries that I should know of?
Patient: Nope, none that I can think of.

assistant: There is no significant past medical history noted today.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: So, I see here in your reports you have arthritis in you both knees.
Patient: Yes.
Doctor: And you got a tear in your eye in the past, right?
Patient: Ah yes, I got a tear in my retina.
Doctor: Right. Also, it's mentioned here that you have atrial fibrillation.
Patient: That's correct.
Doctor: Are you taking any medications?
Patient: Yes, I am on anticoagulants.
Doctor: Okay.

assistant: Atrial fibrillation on anticoagulation, osteoarthritis of the knees bilaterally, h/o retinal tear.
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 medical conditions that run in your family that I should know about, ma'am?
Patient: Um, yeah, my dad had prostate cancer.
Doctor: What about your mother, or the rest of your family?
Patient: Um, my mom's brother had Hodgkin's disease, melanoma, and prostate cancer.

assistant: Her father had prostate cancer. Her maternal uncle had Hodgkin's disease, melanoma, and prostate 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: FAM/SOCHX

Dialogue:
Doctor: Do you drink?
Patient: Not really, no.
Doctor: Any drugs?
Patient: No.
Doctor: Do you get a chance to exercise during the week?
Patient: I like to go on walks with my dog every day. I'm also eating a lot healthier these days.
Doctor: That's wonderful. How's work going for you?
Patient: I actually got promoted last month so it's been going well. I've had a lot more time to spend with my family as a result.
Doctor: That's great to hear. Congratulations!
Patient: Thank you so much.

assistant: No known history of drug or alcohol abuse. Work, diet, and exercise patterns are within normal limits.