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

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Did you had any medical issues in the past?
Patient: No, nothing major.
Doctor: You said nothing major, so, what was there?
Patient: I had a little curve in the spine. It was not major. Doctor said that it can be corrected by exercises.

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

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Do you have any medical conditions that I should know about?
Patient: Yeah, I have chronic diarrhea, and C O P D.
Doctor: Are you a smoker?
Patient: Yes, I have been for a long time.
Doctor: How would you characterize your smoking level?
Patient: Um, I'd say it's pretty heavy.

assistant: Includes chronic diarrhea as I mentioned before and chronic obstructive pulmonary disease secondary to heavy smoking.
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 have atrial fibrillation from the past?
Patient: Yes, rhythm problem is bad.
Doctor: And no dizziness?
Patient: Yes. I do.
Doctor: Okay well...

assistant: 1. Atrial fibrillation. 2. Dizziness.
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 with your husband?
Patient: Yes, we live on a ranch about twenty miles away.
Doctor: Do you have children?
Patient: We had six children all together, but two of them passed away suddenly.
Doctor: I'm so sorry to hear that. How old were they?
Patient: One was forty years old and the other was forty five.
Doctor: Wow, they were quite young. I offer you my sincerest condolences.
Patient: Thank you. It's been really hard on my family, but we're trying our best to get by.
Doctor: That's all you can do. It's important to spend time with each other every chance you get.
Patient: Exactly.
Doctor: I have a few more questions to ask before we end today.
Patient: Go ahead.
Doctor: Do you have family history of any medical problems?
Patient: No.
Doctor: Do you smoke or drink?
Patient: Never.

assistant: She is married, lives with her husband, has 2 children that passed away and 4 surviving children. No history of tobacco use. No history of alcohol use. Family history is 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: PASTMEDICALHX

Dialogue:
Doctor: So let's see here. Any history of high blood pressure or diabetes?
Patient: No, sir.
Doctor: How about heart disease?
Patient: No, no heart disease.
Doctor: And no cancers?
Patient: No and for that I'm thankful.

assistant: None. No history of hypertension, diabetes, heart disease, liver disease or 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: What is your family medical history?
Patient: My dad had Alzheimer's disease. He is in a facility that cares for him now.
Doctor: I am sorry that must be hard.
Patient: It is. My aunt, his sister helped me get everything set up for him. She had a stroke last month.
Doctor: Oh no. How is she doing now?
Patient: She is home now but her husband is having to help take care of her. The doctors said it looks good for her to have a full or almost full recovery.
Doctor: That is a relief.
Patient: Yes, it is!
Doctor: Any other family health problems that you know of?
Patient: No not that I know of.

assistant: Alzheimer's disease and stroke on paternal side of family.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: So, how much longer are you in juvie, young man?
Patient: I've got about three weeks left, sir. Twenty five days, if you want to be exact.
Doctor: Good, time to make the best of getting out, right?
Patient: Absolutely, I don't want to go back.
Doctor: Good. Do you smoke, young man?
Patient: No sir, absolutely not.

assistant: He is in Juvenile Hall for about 25 more days. He is a nonsmoker.
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, I am Doctor Rez. I will ask you a few questions about your personal and family history, okay?
Patient: Yes, that's okay.
Doctor: Did any one in your family get diagnosed with any medical conditions?
Patient: My mom has lumps in her breast but it is benign, however my granny on my father side had cancer.
Doctor: What kind of cancer, do you know?
Patient: Well, it was breast cancer don't know if there are types for it.
Doctor: No, that's fine. Did you ever have palpitations?
Patient: What do you mean by that?
Doctor: Um, Palpitations means the sensation when you feel that your heart is racing or pounding really fast even without doing any strenuous exercise or anything.
Patient: Oh, got it. No, I never had that.
Doctor: What about any uncontrolled urine leakage? Any accidents?
Patient: No.
Doctor: What about any recent sudden hair loss or any other concerns?
Patient: No, nothing like that.
Doctor: Any other treatments in the past?
Patient: Yeah, I recently got treatment for my sinus.

assistant: Benign breast lump in her mother; however, her paternal grandmother had breast cancer. The patient denies any palpitations, urinary incontinence, hair loss, or other concerns. She was recently treated for 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: FAM/SOCHX

Dialogue:
Doctor: Any history of smoking?
Patient: Uh yeah, but I quit in two thousand seven.
Doctor: On average, how many packs per day did you smoke?
Patient: Uh if I were to guess, I'd say one pack per day.
Doctor: Any other drugs?
Patient: I used to do coke, but I quit that in two thousand five.
Doctor: And any history of drinking?
Patient: Um I used to drink one pint per day, but I quit drinking more than ten years ago.

assistant: The patient is a former smoker, reportedly quit in 2007. He used cocaine in the past, reportedly quit in 2005. He also has a history of alcohol abuse, but apparently quit more than 10 years ago.
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: Can you tell me more about your family's medical history? Are there any conditions of note?
Patient: Well, my dad died from prostate cancer, and my mom died as well, she was an alcoholic.
Doctor: I'm so sorry to hear that, ma'am, how old were they?
Patient: Well, my father was eighty, and my mother was sixty seven.
Doctor: I'm so sorry, do you have any siblings?
Patient: Yeah, I had a brother, he passed away too, from bone and throat cancer.
Doctor: I'm sorry, how old was he?
Patient: He was seventy, doctor.
Doctor: Do you have any children?
Patient: I have four, two of each.
Doctor: That's wonderful, how are your sons doing?
Patient: They're thirty seven and thirty eight, and they're both doing really well.
Doctor: That's great, what about your daughters?
Patient: Well, they're sixty and fifty eight, and they both have cancer. They're real fighters.
Doctor: I'm sorry, that must be so hard to deal with. Are there any other conditions you're aware of?
Patient: Oh yeah, we have it all, nervous condition, high blood pressure, kidney and lung disease, depression, it's all there.

assistant: Her father died at the age of 80 from prostate cancer. Her mother died at the age of 67. She did abuse alcohol. She had a brother died at the age of 70 from bone and throat cancer. She has two sons, ages 37 and 38 years old who are healthy. She has two daughters, ages 60 and 58 years old, both with cancer. She describes cancer hypertension, nervous condition, kidney disease, lung disease, and depression in her family.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are you married?
Patient: Yes.
Doctor: Where do you work?
Patient: I work as a secretary in a law firm.
Doctor: Do you smoke or drink? Have you ever tried any illegal drug?
Patient: No, none of these.

assistant: Married, Secretary, No 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: GENHX

Dialogue:
Doctor: It looks like E M S found you in bad shape?
Patient: What?
Guest_family: My mother is hard of hearing. She is eighty five. They found her on the toilet.
Doctor: Did your mother tell you anything about her condition before E M S arrived?
Guest_family: She said she threw up right before they came and she had diarrhea.
Doctor: Ma'am. How are you feeling now?
Patient: I have been sick to my stomach. My belly has been hurting. I threw up.
Doctor: How many times did you vomit ma'am?
Patient: I don't know.
Doctor: Do you recall the color of the vomit? Did you see any blood or notice the color of the vomit?
Patient: I don't know.

assistant: The patient is an 85-year-old female who presents with a chief complaint as described above. The patient is a very poor historian and is extremely hard of hearing, and therefore, very little history is available. She was found by EMS sitting on the toilet having diarrhea, and apparently had also just vomited. Upon my questioning of the patient, she can confirm that she has been sick to her stomach and has vomited. She cannot tell me how many times. She is also unable to describe the vomitus. She also tells me that her belly has been hurting. I am unable to get any further history from the patient because, again, she is an extremely poor historian and very hard of hearing.
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 kids, ma'am?
Patient: Yes, I do. I have two sons and we adopted a girl.
Doctor: Where did you adopt?
Patient: Just here.
Doctor: and you are married right? Are you working?
Patient: Yes, I have been married a long time. I retired from Avon.
Doctor: Do you smoke cigarettes or drink?
Patient: I do not smoke or drink alcohol.

assistant: She has two sons and an adopted daughter. She is married long term, retired from Avon. She is a nonsmoker, 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: GENHX

Dialogue:
Doctor: How's the little dude?
Guest_family: He has fever and bad congestion for the last two days. He has had a fever for one. I try to suck the discharge out through nose.
Doctor: I am guessing he has some mild problems with breathing while feeding.
Guest_family: Yes, that is correct. He is drinking milk every couple hours, only for ten minutes instead of twenty minutes.
Guest_family: He has fever too, so she gave him Tylenol.
Guest_family2: He is very fussy.
Doctor: Is he sleeping well?
Guest_family: Yes, he sleeps. But he is not able to breath well even with albuterol.
Doctor: How about wet and dirty diapers?
Guest_family: He is peeing less I think because he used to have eight to ten wet diapers but now it's down to four in a day. And five dirty diapers.
Doctor: How about any diarrhea?
Guest_family: No, he doesn't have any diarrhea, they are soft and yellow.
Doctor: Any rashes or acne?
Guest_family: No.
Doctor: How about vomiting?
Guest_family: No, he did not vomit.
Doctor: How old is he? And, sorry this is odd, but what ethnicity do you identify as? I need it foe the paperwork.
Guest_family: Twenty one days old Caucasian male.
Doctor: Do you notice him getting blue at all? Or does this area sink in when he tried to breathe?
Guest_family: No, neither.
Doctor: Is he having any trouble breathing in general?
Guest_family: No.

assistant: The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions). One day ago, mom also noticed a tactile temperature and gave the patient Tylenol. Baby also has had some decreased p.o. intake. His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion. He sleeps well, but has been more tired and has been fussy over the past 2 days. The parents noticed no improvement with albuterol treatments given in the ER. His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours. Mom denies any diarrhea. His bowel movements are yellow colored and soft in nature. The parents also noticed no rashes, just his normal neonatal acne. The parents also deny any vomiting, apnea.
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 taking Benicar?
Patient: Yes, twenty daily.
Doctor: And what else?
Patient: I take some multivitamin, glucosamine, Vitamin B complex, Vitamin E and a low dose Aspirin.
Doctor: Okay that's good information.

assistant: Benicar 20 mg daily; multivitamin; glucosamine; vitamin B complex; vitamin E and a low-dose aspirin.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you smoke?
Patient: Nope.
Doctor: How about alcohol intake?
Patient: Nope.
Doctor: What about any kind of drug usage?
Patient: Nope.

assistant: Denies ETOH/illicit drug/Tobacco 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: EDCOURSE

Dialogue:
Doctor: Hi, how are you?
Patient: I am okay.
Doctor: Do you have any bone pain or issues around that?
Patient: No, I do not.
Doctor: So, they gave you a dose of Tylenol here in the emergency department to treat your pain. Is your pain under control?
Patient: Yes, with medication I feel it is better, but I want to be removed from the backboard.
Doctor: Okay, let's get you off. Yeah, your C T scans of the abdomen appeared normal. And there was no sign of bleeding. I believe, you just have a contusion and abrasion to abdomen from the seatbelt and likely from the airbag as well.
Patient: Oh okay.
Doctor: It's good that you can stand and walk through the emergency department without difficulty. I do not see any abrasions or lacerations.
Patient: Yeah, nothing like that and I can walk.

assistant: The patient was removed from the backboard within the first half hour of her emergency department stay. The patient has no significant bony deformities or abnormalities. The patient is given a dose of Tylenol here in the emergency department for treatment of her pain. Her pain is controlled with medication and she is feeling more comfortable and removed from the backboard. The patient's CT scans of the abdomen appeared normal. She has no signs of bleeding. I believe, she has just a contusion and abrasion to her abdomen from the seatbelt and likely from the airbag as well. The patient is able to stand and walk through the emergency department without difficulty. She has no abrasions or lacerations.
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: Lets talk about your family history, does cancer run in your family ma'am?
Patient: Oh yes! My family has a history of lung, liver and prostate cancer.
Doctor: Oh wow!
Patient: Yeah.
Doctor: And you mentioned that your mother had Alzheimer's?
Patient: Well, I am not sure about Alzheimer, but she had some dementing disease. It started when she was in her eighties. It was kind of mild case.
Patient: And she actually passed away in her eighties due to old age.
Doctor: Okay, how about your siblings, do they have any signs of Alzheimer?
Patient: No, they are fine.
Doctor: Okay.

assistant: Significant for lung, liver, and prostate cancer. Her mother died in her 80s of "old age," but it appears that she may have had a mild dementing illness at that time. Whatever that dementing illness was, appears to have started mostly in her 80s per the patient. No one else appears to have Alzheimer disease including her brother and sister.
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:
Guest_clinician: What's their medical history?
Doctor: I have here hypertension, diabetes, diabetic retinopathy, and elevated lipids. They're in post C V A.
Guest_clinician: Do you know their neurologist?
Doctor: I can have the nurse or scribe go in and ask again.
Guest_clinician: Great.

assistant: Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy.
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:
Guest_clinician: Were you able to get a history from her?
Doctor: I tried but was unsuccessful. She's very out of it.
Guest_clinician: Does she have a history of alcohol abuse?
Doctor: According to her records, she has a long history of alcohol abuse.

assistant: Significant for alcohol abuse. Unable to really gather any other information because she is so obtunded.
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: The patient has a history of C A D.
Guest_clinician: Are they being followed by a cardiologist?
Doctor: Not to my knowledge. I can check their electronic medical records. One sec.

assistant: Positive for 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: GENHX

Dialogue:
Doctor: Hi sir, how old are you?
Patient: I am thirty.
Doctor: We are following up today for your moderate to severe apnea, right?
Patient: Yes, that is correct, I still can't sleep.
Doctor: Okay and you did the CPAP?
Patient: Yes.
Doctor: Okay, let's review it today.
Patient: Sure.

assistant: Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea. He returns today to review his response to CPAP.
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: Any smoking or alcohol?
Patient: No, I don't smoke but I drink wine.
Doctor: Are you married?
Patient: Yes, I am.
Patient: I have three stepchildren and one of my own and I work for A B C D.

assistant: He is a non-cigarette smoker. He has occasional glass of wine. He is married. He has one biological child and three stepchildren. He works for ABCD.
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: Congratulations on your new baby! How are you doing today?
Patient: I'm doing well, no headaches, and I'm breastfeeding well.
Doctor: Have you had any bleeding?
Patient: Nope, none.
Doctor: Are you using a mini pad?
Patient: Yeah, I use it twice a day.
Doctor: Do you have any cramping or clotting?
Patient: No, thankfully I don't.
Doctor: What color is your discharge, ma'am?
Patient: Well, its turned from red to brown, and now its kind of yellowish.
Doctor: Okay, have you had sex again yet?
Patient: No, we're waiting a little longer.
Doctor: Are you going to the bathroom regularly?
Patient: Regularly? Yes, but I'm having some pain with it, and then every once in a while I have some bright red bleeding.
Doctor: Are you constipated?
Patient: No, I'm not.
Guest_family: She hasn't been eating her vegetables like she should.
Doctor: That'll also do it.
Patient: Okay, well, my seasonal allergies are back too.
Doctor: What symptoms do you have with your allergies?
Patient: I get itchy watery eyes, a runny nose, I can't stop sneezing, and I have a lot of pressure in my ears.

assistant: She is doing well postpartum. She has had no headache. She is breastfeeding and feels like her milk is adequate. She has not had much bleeding. She is using about a mini pad twice a day, not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish. She has not yet had sexual intercourse. She does complain that she has had a little pain with the bowel movement, and every now and then she notices a little bright red bleeding. She has not been particularly constipated but her husband says she is not eating her vegetables like she should. Her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes, runny nose, sneezing, and kind of a pressure sensation in her ears.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you have any major medical conditions that run in your family that I should know about?
Patient: What do you mean by that?
Doctor: Well, it could be anything from diabetes to high blood pressure to cancer.
Patient: Oh, yeah. My brother had prostate cancer.

assistant: His brother had 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: GENHX

Dialogue:
Doctor: Hi, how are you?
Patient: Hi! I am okay other then this back pain.
Doctor: I am so sorry. Tell me about your back.
Patient: Three nights ago, I fell on my steps bringing in the groceries from the car.
Doctor: How did you land when you fell?
Patient: I fell and landed on my right hip. I hit my low back on the railing.
Doctor: I would like to get some imaging done today.
Patient: Okay.

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

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Have you seen your lab results?
Patient: No, do you have those in today?
Doctor: Yes, I have them right here. They're essentially negative, except it appears that you had C difficile in the past. Do you remember that?
Patient: Yes, I got it when I worked at a hospital after graduating.
Doctor: Yeah, its unfortunately more common there.

assistant: Essentially negative other than he has had C. difficile in the recent 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: EXAM

Dialogue:
Doctor: Breath in breath out, let me tap it and see. Well, your lungs sound clear.
Patient: Okay.

assistant: CHEST: Lungs bilaterally clear to auscultation and percussion.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: MEDICATIONS

Dialogue:
Doctor: Are you still taking the Trizivir?
Patient: Yes.
Doctor: How much are you taking?
Patient: I take one pill two times a day.
Doctor: Are you taking any other medications?
Patient: I take Ibuprofen for body aches from time to time but that's it.

assistant: 1. She is on Trizivir 1 tablet p.o. b.i.d. 2. Ibuprofen over-the-counter p.r.n.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: I just need to confirm some information before we begin sir, you're forty one, correct?
Patient: Yes sir, that's correct.
Doctor: Good, so what happened?
Patient: Well, I work at A B C, and about two days ago I slipped on some oil that had spilled.
Doctor: How did you fall?
Patient: I fell with both my arms outstretched, but I fell mostly on my left shoulder.
Doctor: Where is your left shoulder pain?
Patient: Mostly, it's in the back of my shoulder.
Doctor: Going backwards a little, how about the right shoulder?
Patient: It hurt really bad yesterday, but that's gone away now.
Doctor: Good, do you have any pain in the front of the shoulder?
Patient: No sir, I don't have anything there.
Doctor: Good, how about weakness? Is there any shoulder weakness?
Patient: No, it's not really weak at all.
Doctor: How have your symptoms progressed over the last two days? Have they gotten better, or worse?
Patient: Um, overall, I'd say it's gotten better. I have a little better range of motion.
Doctor: Have you been able to do any activities?
Patient: I was able to get in the swimming pool with my kids, and I didn't really have any trouble.
Doctor: Good, what medicines have you taken for this?
Patient: I've just taken some Advil so far.

assistant: The patient is a 41-year-old male presenting for initial evaluation of his left shoulder. He works at ABC and two days ago was walking though an area, where there was some oil spilled on the floor. He fell and landed on bilateral outstretched arms and then further fell landing primarily on his left shoulder. He presents today reporting primarily posterior shoulder pain. The right shoulder was bothersome yesterday, but is now asymptomatic. He has no anterior shoulder pain. He denies any feelings of weakness. He reports some improvement over the last two days especially in his range of motion. He was able to get into the swimming pool last night with his children without difficulty. He has had no additional treatment other than over-the-counter Advil.
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: Hi there! It is good to see you both. How has everything been going for the both of you?
Patient: Hi Doctor.
Guest_family: Things have been pretty good. She has been having some new emotional outbursts. I made an appointment with the down syndrome behavioral specialist that you recommended from the last time we were here.
Doctor: That is great. Keep me updated on her progress. Her bloodwork came back showing an underactive thyroid. This explains the recent weight gain and fatigue. I would like to start her on a medication called levothyroxine. We will need to check her bloodwork again in one month to see how her thyroid respond to the medication.
Guest_family: Okay.
Doctor: Is there any other concerns you have today?
Guest_family: Yes. She has this toenail that looks strange and discolored.
Doctor: Let me look. Can you remove your socks for me?
Patient: Yes.
Doctor: Is it this nail?
Guest_family: Yes.
Doctor: This is very common. It is called Onychomycosis. It is nail fungus. Since only one nail is affected, I would recommend starting off with a topical treatment. I will send the drops to your pharmacy. You will put on drop on the affected nail, daily.

assistant: 1. Down's syndrome. 2. Onychomycosis. 3. Hypothyroidism.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTSURGICAL

Dialogue:
Doctor: Good afternoon, ma'am.
Patient: Good afternoon, doctor.
Doctor: Have you ever had surgery, ma'am?
Patient: Actually, yes I have. I had pinning surgery done on both of my ears.
Doctor: Do you remember how old you were when you had surgery?
Patient: Um, I was five or six years old. It was when I was a kid, I know that for sure.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: What is your family medical history?
Patient: My dad has high blood pressure. My mom has had a ton of skin cancer removed.
Doctor: Do you know what type of skin cancer she has removed?
Patient: I have no idea.

assistant: HTN and multiple malignancies of unknown type.
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. Today we're going to do a recheck for your hypertension. Sound good?
Patient: Yes, of course.
Doctor: I just want to check to see if you have any symptoms that can possibly raise alarm.
Patient: I have been coming to you for the last fifteen of my seventy eight years on Earth. I know how a follow up works.
Doctor: You are a seasoned veteran. Alright. So how is your chest? Any pains or tightness?
Patient: No, luckily I do not have that.
Doctor: Is your heart beating alright? Do you feel like it is beating too fast or hard?
Patient: No. I can't really feel my heart beat normally, but I guess that is better than feeling it beat constantly.
Doctor: You are correct. You shouldn't notice it. How is sleeping?
Patient: Sleeping has been fine. I sleep through the night.
Doctor: Great. Any shortness of breath that causes you to wake up?
Patient: None. I don't have shortness of breath at any other time of the day.
Doctor: Are your legs doing well? Any swelling?
Patient: No. No swelling.

assistant: The patient is a 78-year-old female who returns for recheck. She has hypertension. She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema.
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, it's nice to meet you.
Patient: It's nice to meet you as well.
Doctor: My name is Doctor X and I will be taking care of you today.
Patient: Thank you.
Doctor: I've been told that you'd like a refill on your Xanax prescription and something to help you break your smoking habit.
Patient: Yes, I feel like I've tried everything in the book and I still can't break the habit. One of my buddies was telling me about this medicine called Clantix or something like that.
Doctor: Yes, I've heard of Chantix. We can look into it and see what's best fit.
Patient: Okay, great. Since moving back home, I've ran out of Xanax.
Doctor: How long have you been taking it?
Patient: Almost a year now. I usually take it on days where my anxiety is really bad.
Doctor: I see here that you also have mesothelioma in the lining of your stomach, is that correct?
Patient: Yes, I need to find a new cancer specialist that's closer to where I live.
Doctor: Are you currently experiencing any pain?
Patient: Not at the moment, but I do get pain when I eat sometimes. Other times it's when I'm not even doing anything. It's been chronic so nothing new.
Doctor: Do you take anything for the pain?
Patient: I haven't in a while.
Doctor: When were you diagnosed with mesothelioma?
Patient: About six or so months ago.

assistant: The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking. She is a new patient today. She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain. She states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office. She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try.
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?
Doctor: Like any medications?
Patient: No, I am not allergic to anything.
Doctor: Perfect!
Patient: Hm.

assistant: None.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ASSESSMENT

Dialogue:
Doctor: I mean, I am so happy to see your report today, your blood pressure looks much better. That's amazing given your past few visits your B P was out of control and even with changing your medications we were having tough time bringing it down.
Patient: Yeah, I feel much better, I read about my condition and it is called something as um refraction or--
Doctor: Refractory hypertension.
Patient: Oh yeah that!
Doctor: But the good news is that it is getting better.
Patient: Yes.
Doctor: Last time we talked about seeing the internal medicine doctor there at your senior center, right?
Patient: Yes, I made an appointment last week, um, no week before that, but I completely forgot about it.
Doctor: Hm, okay we need to reschedule that.
Patient: Yes, I will do it today.
Doctor: Okay, your reports look fine. G F R is below sixty percent, that's a good sign. Overall, Miss K, you look better, but we need to reschedule your appointment with the Internist. That's kind of important.
Patient: Okay, I will do that. Thank you!
Doctor: You are welcome.

assistant: This is a return visit for this patient who has refractory hypertension. This seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously. We had discussed with her in the past beginning to see an internist at the senior center. She apparently had an appointment scheduled and it was missed. We are going to reschedule that today given her overall state of well-being and the fact that she has no evidence of GFR that is greater than 60%.
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! How are doing today?
Patient: I am doing well.
Doctor: How have you been doing with keeping your hemoglobin levels between four and five point six prercent?
Patient: I have been doing well. I have been able to keep it within that range.

assistant: Followup diabetes mellitus, type 1.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: So, are you married, ma'am?
Patient: Well, no I'm not. My husband and I got a divorce.
Doctor: I'm sorry to hear that, do you have any children?
Patient: It's okay, it was for the best. Yes, I have two.
Doctor: Do you live with either of them?
Patient: Yeah, um, I live with my son right now.
Doctor: Do you smoke or drink?
Patient: No I do not.

assistant: Denies any tobacco or alcohol use. She is divorced with 2 children. She lives with 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: GENHX

Dialogue:
Doctor: Good afternoon, so, who is the patient today?
Guest_family: Good afternoon, doctor. My granddaughter is your patient today.
Doctor: What seems to be the problem today, young lady?
Patient: Well, I'm having a lot of headaches, I feel it in my face.
Doctor: Does it feel like pressure?
Patient: That, and I have the sniffles.
Doctor: What other symptoms have you had?
Patient: Um, well, last night I had a sore throat, and I was coughing up phlegm.
Doctor: Interesting, anything else?
Patient: Um, I've had a rash on my face, back, and arms for the last three days or so.
Doctor: Is it itchy?
Patient: Yes, so we've been taking a lot of Benadryl.
Doctor: I see, are you going to school?
Patient: I have been, there's been a lot of fifth disease this year.
Doctor: Okay, and have you been wheezing lately?
Patient: No, I haven't been.
Doctor: I see you have asthma, have you had any medication for this?
Patient: No, I haven't had anything.

assistant: Grandfather brings the patient in today because of headaches, mostly in her face. She is feeling pressure there with a lot of sniffles. Last night, she complained of sore throat and a loose cough. Over the last three days, she has had a rash on her face, back and arms. A lot of fifth disease at school. She says it itches and they have been doing some Benadryl for this. She has not had any wheezing lately and is not taking any ongoing medications for her asthma.
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: Did you have any surgeries in the past?
Patient: Yes, I had a partial removal of my ovaries and then I also had my appendix removed.
Doctor: Okay anything else?
Patient: Yeah, I also got my tummy tucked.
Doctor: Okay.

assistant: Significant for partial oophorectomy, appendectomy, and abdominoplasty.
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, young man.
Patient: Hello, doctor.
Doctor: How old are you, young man?
Patient: I'm thirteen, sir.
Doctor: Thank you, so, what happened?
Patient: I sliced my right ring finger with a piece of glass while I was playing around with my friends.
Doctor: You need to be more careful, young man. What kind of symptoms do you feel in that finger?
Patient: You're right. I have a lot of, um, numbness and tingling in it.

assistant: This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Hello. How are you feeling today?
Patient: Not so well. I went to a party last night and my chest and body have been hurting a lot.
Doctor: I see. Did you smoke at the party?
Patient: Nope. I never smoked in my life.
Doctor: Great. Where on your body does it hurt?
Patient: Like my upper right side of my stomach area.
Doctor: I see. Did you drink alcohol last night?
Patient: I had to drive some people home, so I was sober. I also don't like the taste of alcohol, so I stay away from it.

assistant: Denies tobacco or alcohol 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: PLAN

Dialogue:
Patient: And do I have to restrict my movement or activities?
Doctor: Um, I have taken the plaster off and your foot looks good. I don't want you to restrict your activities, but you are the best judge of the situation. So, I will advise you to take it slow and do as much as you can tolerate.
Patient: Got it. Thank you, Doctor. Do I need a follow-up?
Doctor: As long as you are doing fine, having no pain, I think we are okay.
Patient: Alright then bye.
Doctor: Bye.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: What is your family medical history?
Patient: My dad had stomach cancer.
Doctor: How old was he when he was diagnosed?
Patient: I think he was seventy something. My sister has breast cancer. She is in her fifty's.
Doctor: Any family history of uterine, ovarian or colon cancer?
Patient: No. Not that I am aware of.

assistant: 1. A sister with breast carcinoma who was diagnosed in her 50s. 2. A father with gastric carcinoma diagnosed in his 70s. 3. The patient denies any history of ovarian, uterine, or colon cancer in her family.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you drink or smoke?
Patient: No I don't. I have to care for my daughter. She is a widow.
Doctor: So you live with her?
Patient: Yes, she lives at home.

assistant: She denies alcohol or tobacco use. She is the caretaker for her daughter, who is widowed and lives at 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: PASTMEDICALHX

Dialogue:
Doctor: Any known past medical history?
Patient: I have high blood pressure.
Doctor: Anything else?
Patient: Yeah, I remember I also had higher number of fat in my blood.

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

user: Section: GENHX

Dialogue:
Doctor: Good morning, ma'am, welcome in. I believe this is our first time meeting.
Patient: Good morning, doctor. Yes, this is my first time in.
Doctor: Great, how old are you?
Patient: I'm fifty five, doctor.
Doctor: Thank you, what seems to be the problem today?
Patient: Well, I'm having a laundry list of symptoms coinciding with my allergies.
Doctor: Like what, ma'am?
Patient: Well, my sense of taste is diminished, dry mouth, um, acid reflux, and G I issues, and then I have asthma, and reactions to things like aerosols.
Doctor: I see, do you have any food allergies?
Patient: Um, I think.

assistant: A 55-year-old female presents self-referred for the possibility of evaluation and treatment of allergies, diminished taste, xerostomia, gastroesophageal reflux disease, possible food allergies, chronic GI irritability, asthma, and environmental inhalant allergies. Please refer to chart for history and physical and review of systems and detailed medical history.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: What's your family history?
Patient: Both my parents are deceased.
Doctor: I'm so sorry to hear that. I offer you my sincerest condolences.
Patient: Thank you. My dad passed away at seventy five from leukemia and my mom fell victim to heart problems and alcoholism at thirty eight.
Doctor: Does anyone else in your family suffer from leukemia, cardiac problems, or alcohol abuse?
Patient: One of my uncles on my dad's side was recently diagnosed with leukemia.
Doctor: Oh, wow. I see.

assistant: Positive for mother passing away at the age of 38 from heart problems and alcoholism, dad passed away at the age of 75 from leukemia. One of her uncles was diagnosed with leukemia.