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: CC

Dialogue:
Doctor: Hi there, how is it going?
Guest_family: Hi doctor, I am his son Ethan.
Doctor: Nice to meet you.
Doctor: So, I see your father has a history of drug abuse, right?
Guest_family: Yes.
Patient: Not abuse, I just used to do drugs. The last time I really made a big mistake I injected the heroine directly into both of my thighs and unfortunately, I got these ulcers which are not going away.
Doctor: Yeah, this is really unfortunate. I can see these open wounds, it's because of the chronic abscesses.
Guest_family: The right thigh looks worse than the left one.
Doctor: Yeah, I see that. How old is your father?
Guest_family: He is sixty two.
Doctor: Does he have any other medical issues like sugar or blood pressure?
Guest_family: No.
Doctor: Okay, I think we need to surgically remove this whole area and then do a reconstruction.
Guest_family: And is that the only way?
Doctor: According to me, yes! I mean the wounds are not healing and it is only getting worst.
Guest_family: Okay then we will follow whatever you suggest.
Doctor: Okay.

assistant: The patient is a 62-year-old male with a history of drug use. He had a history of injection of heroin into his bilateral thighs. Unfortunately, he developed chronic abscesses, open wounds on his bilateral thighs, much worse on his right than his left. Decision was made to do a radical excision and then it is followed by reconstruction.
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 or use any tobacco products, miss?
Patient: No.
Doctor: Do you drink alcohol and if so, how many drinks do you consume in a typical week?
Patient: I don't drink.
Doctor: Do you use any recreational drug or other substances?
Patient: No.
Doctor: Do you have children?
Patient: Yes. I have three kids.
Doctor: Do your children have any health conditions?
Patient: No.
Doctor: Are you married?
Patient: Yes.

assistant: Married, 3 children who are healthy. She denied any Tobacco/ETOH/Illicit drug use.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: How is your family doing?
Patient: They all are good.
Doctor: Are you aware of any medical issues in your family?
Patient: No, not to my knowledge.

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: PASTMEDICALHX

Dialogue:
Doctor: Have you ever had spine problems before?
Patient: What, like an injury?
Doctor: Well, it's broad. It could be an injury, or just any kind of pain.
Patient: Oh, no. I've never had any problems.

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

user: Section: GENHX

Dialogue:
Doctor: With ten being the worse pain ever, how would you rate your pain out of ten today, ma'am?
Patient: Um, out of ten, I'd say it's about a two.
Doctor: That's good. What helps the pain feel better?
Patient: Um, it gets better with elevation, and when I just rest.

assistant: The patient rates the pain at 2/10 on the pain analog scale. The patient states that with elevation and rest, her pain subsides.
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: I used to drink before, but now I have stopped it completely.
Doctor: How would you rate your pain?
Patient: It is tolerable, like five out of ten but I do need some pain medications.
Doctor: Then why do you need more pain medications?
Patient: Sometimes it gets hard, I really need some more pain medications.
Doctor: Do you have morphine? Do you need more?
Patient: I don't like morphine. Can you change it to Dilaudid? I like that medicine. That one works for me great.

assistant: History of alcohol use in the past. He is basically requesting for more and more pain medications. He states that he likes Dilaudid and would like to get the morphine changed to Dilaudid. His pain is tolerable.
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: She has a vast history of surgeries.
Doctor: Yeah, I am looking at her reports. She had surgery for spina bifida when she was a baby and they had to put a shunt.
Guest_clinician: Yeah, later she had her uterus removed and also had to undergo a breast reduction surgery.
Doctor: Hm.

assistant: Back closure for spina bifida, hysterectomy, breast reduction, and a shunt.
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 or divorced?
Patient: I am married.
Doctor: Okay.
Patient: Hm.
Doctor: Do you smoke cigarettes or drink alcohol?
Patient: No, I have never.

assistant: She is married and does not smoke or drink nor did she ever.
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. My chart says that you're forty nine years old, and White, is that correct?
Patient: Yes, that's all correct.
Doctor: What do you do for a living?
Patient: I'm a secretary.
Doctor: Great, welcome back to the Dermatology office, do you remember when your last appointment was?
Patient: Um, I think it was on August tenth two thousand four.
Doctor: Good, that's what I have here as well, so has your acne improved since your last visit?
Patient: Well, not really, and I think I have a rash too.
Doctor: How long have you been dealing with this?
Patient: Um, at this point it's been about two months.
Doctor: Where do you see this rash?
Patient: Um, it's right here, on my chest, stomach, neck, and back, it's all over my upper body.
Doctor: I see, it appears that your acne is flaring, and there are small lesions on the follicles as well. Have you been taking your Amoxicillin and using your Tazorac?
Patient: Yeah, I taken five hundred M G of amoxicillin twice a day, and I use the cream as well.
Doctor: Good, the acne on your face appears to be clearing.
Patient: Thank you, I've been out of medicine for about three days now though.
Doctor: Okay, we might refill that. Have you had any other treatments aside from what I've done? I
Patient: Um, my husband drove me to Healing Waters and they did, um, photofacials. Is there anything that can be done in the office today, like, um, cosmetic procedures, or do you have any skin care products? I want to keep up my appearances since I work the front office as a secretary.

assistant: The patient is a 49-year-old white female, established patient to Dermatology, last seen in the office on 08/10/2004. She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and back. On examination, this is a flaring of her acne with small folliculitis lesions. The patient has been taking amoxicillin 500 mg b.i.d. and using Tazorac cream 0.1, and her face is doing well, but she has been out of her medicine now for three days also. She has also been getting photofacials at Healing Waters and was wondering about what we could offer as far as cosmetic procedures and skin care products, etc. The patient is married. She is a secretary.
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: It looks like your Xrays show bronchitis.
Patient: Is there anything I can take for it?
Doctor: Yes, I'm going to prescribe you something that will help clear your lungs.

assistant: Bronchitis/URI.
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 X Y Z? I see you're in a walking boot. What happened?
Patient: I hurt my foot pretty bad yesterday.
Doctor: How'd it happen?
Patient: Basketball. I play for the University of Houston. I went up for a three and came down and landed on this guy's foot. I was so pissed.
Doctor: Dang, that sucks. Were you guys playing a home game?
Patient: We were traveling to Duke. We could've won the game if I didn't get hurt.
Doctor: You'll get them next time. Did you keep playing?
Patient: Yeah, I did. I got taped up by the trainer, and I went back into the game.
Doctor: I see. Who was the trainer that helped you?
Patient: His name is John Houston. Do you know him?
Doctor: Oh, John! He's a good friend of mine.
Patient: Yeah, he told me to come see you. He checked my foot. Here's the notes he wrote.
Doctor: It looks like you have some tenderness around your navicular, which is a bone in your ankle.
Patient: Dang, that's whack.
Doctor: Which way did you twist your ankle?
Patient: My foot twisted inwards. Kind of like this.
Doctor: I see. Your foot inverted. Did it swell up right away?
Patient: Aw, man. My foot was huge right after it happened. It hurt so much too.
Doctor: Continue to keep that tape on. Are you limping or anything?
Patient: Yeah, I am. I can't really put weight on my foot because it'll hurt a lot.
Doctor: I see. Well, I examined your foot, and it looks like the pain is around the top, back and middle of your foot.

assistant: XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to continue playing He was examined by John Houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. He has been in a walking boot. He has been taped firmly. Pain with weightbearing activities. He is limping a bit. No significant foot injuries in the past. Most of his pain is located around the dorsal aspect of the hindfoot and midfoot.
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:
Guest_family: So apart from constipation what is his problem? What is up with his lungs?
Doctor: Yeah so, we call it foreign body impaction. It is mostly affecting his right nostril and as you said there is constipation.

assistant: 1. Infected foreign body, right naris. 2. Mild constipation.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Patient: I was working when it happened so we are going through workers comp.
Doctor: Okay. Don't worry. Let's see. Oh wow!
Patient: Yeah, this arm, it was a hot oil.
Doctor: Yeah, too bad, looks like from elbow to wrist. The whole medial side is burnt.
Patient: I am using cool packs since it happened. My friend is helping me so much, he drove me to Emergency Department.
Doctor: Okay, how old are you?
Patient: I am forty one.
Doctor: What is your job? I mean what do you do?
Patient: I am a cook at coffee shop.

assistant: This is a Workers' Compensation injury. This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. He has had it cooled, and presents with his friend to the Emergency Department for care.
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: Um, I have high blood pressure, and asthma.
Doctor: I also see here that you have cervical cancer, can you tell me more about that?
Patient: Yeah, I got diagnosed at fifteen years old.
Doctor: How would you describe the progression of your cancer?
Patient: Now, um, I'd say it's dormant.

assistant: Significant for hypertension, asthma, and cervical cancer. The cervical cancer was diagnosed as 15 years old. The patient states that her cancer is "dormant."
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: MEDICATIONS

Dialogue:
Doctor: Do you take anything for acid reflux?
Patient: Yeah, I take Aciphex.
Doctor: Is that twenty M G once a day?
Patient: It is. I also take one baby Aspirin in the mornings.

assistant: Aciphex 20 mg q.d. and aspirin 81 mg q.d.
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: Yes.
Doctor: How much do you smoke?
Patient: I smoke about two packs of cigarettes a day.
Doctor: Okay.

assistant: Smokes 2ppd cigarettes.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ROS

Dialogue:
Doctor: Any numbness or tingling?
Patient: No.
Doctor: Are your experiencing any muscle weakness?
Patient: No.
Doctor: Any problem walking, or did you lose balance or fall?
Patient: Nope.
Doctor: So, your gait is fine. Any stroke in the past?
Patient: No, nothing like that.

assistant: NERVOUS SYSTEM: No gait problems, strokes, numbness or muscle weakness.
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: Past surgeries I should know of?
Patient: I had my gallbladder, appendix, and uterus removed.
Doctor: Oh wow, I see. When did you get these surgeries?
Patient: I had my gallbladder removed in O eight, appendix removed in twenty twelve, and uterus removed this past year.
Doctor: Any other medical history?
Patient: My bladder was sagging the last time I saw the urologist.
Doctor: Does the diagnosis bladder prolapse sound familiar?
Patient: Yeah, I believe so. They said it was grad four last time.
Doctor: Have you followed up with your urologist recently?
Patient: Chip Winkel? No, not as of late.

assistant: Significant for cholecystectomy, appendectomy, and hysterectomy. She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.
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: Do you have allergies? How old are you, young man?
Patient: Yes ragweed. I am twelve.
Doctor: So basically, you are just congested?
Patient: Yes that's right. The last ten days.
Doctor: Any headache? What comes out of your nose?
Patient: Yes I had a little yesterday. Clear boogers.
Doctor: You feel hot?
Patient: No.
Doctor: Anyone sick at home?
Guest_family: No.

assistant: This is a 12-year-old young man who comes in with about 10 days worth of sinus congestion. He does have significant allergies including ragweed. The drainage has been clear. He had a little bit of a headache yesterday. He has had no fever. No one else is ill at home currently.
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: I'm divorced.
Doctor: Do you have any kids?
Patient: Yes, I have two boys and they live with me.
Doctor: Any abnormal pregnancy. Any abortions?
Patient: No, none of them.
Doctor: Do you smoke or consume alcohol or have ever used any illicit drug?
Patient: No.

assistant: Divorced. Lives with children. No spontaneous abortions. Denied ETOH/Tobacco/Illicit Drug use.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: I want to go over your medical history. I see here you saw the dermatologist a month ago.
Patient: Yeah. She said that I um have an overactive sweat gland.
Doctor: Does hidradenitis suppurativa sound familiar?
Patient: It does.
Doctor: I ask because it's also included in your last visit with your dermatologist.
Patient: Those are the red bumps, right?
Doctor: Yes. There's a note here that you could've potentially had Staph with it as well.
Patient: Oh yeah. I've also had a lot of abscesses in the past.
Doctor: It looks like you've had them in your upper mid thigh, vulva area, and the area between your vulva and anus.
Patient: For about two years now.
Doctor: Right. And a history of asthma?
Patient: Correct.

assistant: 1. History of recurrent abscesses in the perineum, upper medial thigh, and the vulva area for about 2 years. Per her report, a dermatologist had told her that she had an overactive sweat gland, and I believe she probably has hidradenitis suppurativa. Probably, she has had Staphylococcus infection associated with it as well. 2. Reported history of 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: PASTMEDICALHX

Dialogue:
Patient: Hello, how are you?
Doctor: I am good, tell me what brings you here?
Patient: I am having this chest pain. I was hospitalized last year in October and at that time they put this catheter in my heart. I also underwent a heart scan. It's here in this report.
Doctor: Yeah, I see that you got nuclear and myocardial perfusion scan, which was normal. They were looking for some heart artery lesion but then it was thought to be due to spasm.
Patient: Right.
Doctor: It is also mentioned here that you have hyperlipidemia.
Patient: Yes.
Doctor: And are you still smoking?
Patient: Yes, in fact I have been smoking actively from pass three to four days because I am really stressed.
Doctor: Hm. And would you say, you might have had some exertion recently or did some steep hiking or some cardio exercises which might have caused some additional stress on your heart causing chest pain?
Patient: No, I did not do any exertion. Just actively smoking that's all.

assistant: Hyperlipidemia, smoking history, and chest pain. He has been, in October of last year, hospitalized. Subsequently underwent cardiac catheterization. The left system was normal. There was a question of a right coronary artery lesion, which was thought to be spasm. Subsequently, the patient did undergo nuclear and myocardial perfusion scan, which was normal. The patient continues to smoke actively since in last 3 to 4 days especially when he is stressed. No relation to exertional activity.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: I am sorry about that.
Patient: Yes, for assault, that's why I was in detention.
Doctor: Okay.
Doctor: When was this?
Patient: Around December of two thousand nine.
Patient: Not sure if I am under legal contraints right now.
Doctor: Okay so we don't know.

assistant: He had an assault in December 2009, which led to his previous detention. It is unknown whether he is under legal constraints at this time.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you smoke cigarettes?
Patient: Yes, I do.
Doctor: How many packs a day.
Patient: Maybe one a day.
Doctor: Okay, you should think about quitting.

assistant: The patient is still a smoker.
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: What happens when you take Sulfa drugs?
Patient: Oh man, I get a really ugly looking rash.
Doctor: I'll make note of that so we have it in your chart.

assistant: Sulfa (rash).
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 or drink alcohol?
Patient: No.
Doctor: Any use of recreational substances or IV drug abuse?
Patient: No.

assistant: The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Tell me what brings you here today?
Patient: I'm having some issues with my right hand.
Doctor: What kind of issues?
Patient: I'm having these pins and needles kind of feeling in my hand and it has been going on for several weeks. Sometimes I feel it gets numb. I think it might be carpal tunnel, but I'm not sure. I'm just worried.
Doctor: Did you do anything for it?
Patient: At work I recently moved my keyboard down. I just hope it will help. You know, I do a lot of the same kind of activities all the time. All of it I typing based.
Doctor: What is more difficult, day or night?
Patient: It gets worse at night. If I sleep on it, like in a certain way, it will just wake me up and it starts hurting. These tingling sensations are the worst. It helps if I shake it then the sensation goes away. It irritates me all the time.
Doctor: Is it complete hand or is there any part of hand that is worse than others?
Patient: It is mostly my middle finger, but maybe my first or second finger of the hand also, but mostly my middle finger.
Doctor: Is there pain anywhere else?
Patient: In my thumb as well. I'm just afraid it can be arthritis. I don't want that, too, on my plate.

assistant: This patient presents to the office today because of some problems with her right hand. It has been going tingling and getting numb periodically over several weeks. She just recently moved her keyboard down at work. She is hoping that will help. She is worried about carpal tunnel. She does a lot of repetitive type activities. It is worse at night. If she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her. It involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand. She has some pain in her thumb as well. She thinks that could be arthritis.
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: Have you been in any accident?
Patient: I have been a truck driver for some time but luckily have not been in any major auto accident. I had hit a moose once, where I bumped my head but do not remember getting hurt anywhere else. I had broken my ankle in the past.
Doctor: Hm, I see here you mentioned to the nurse, that a car fell on your chest six years back?
Patient: Oh yes, I was repairing my car and it fell off the car jack stand and fell on my chest but fortunately I was not hurt.

assistant: He had a broken ankle in the past. They questioned the patient who is a truck driver whether he has had an auto accident in the past, he said that he has not had anything major. He said he bumped his head once, but not his chest, although he told the nurse that a car fell on his chest that is six years ago. He told me that he hit a moose once, but he does not remember hitting his chest.
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: Did you ever had pneumonia?
Patient: No, never.
Doctor: Do you have any history of lung disease?
Patient: No.
Doctor: Any history of tuberculosis?
Patient: No.
Doctor: Are you feeling any shortness of breath or difficulty breathing?
Patient: No.
Doctor: Okay. Do you have any wheezing?
Patient: No.

assistant: RESPIRATORY: No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.
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: Tell me about your past medical history. Is there anything that I should be aware of?
Patient: No, I don't think so.
Doctor: Any known allergies?
Patient: No.
Doctor: Have you ever been diagnosed with diabetes or high blood pressure?
Patient: Oh, last year I did have some incidents of high blood pressure, but I didn't take any medications for it.
Doctor: Have you seen any variation in your weight?
Patient: How do you know? It's been up. About fourteen pounds since last year.

assistant: Unremarkable. There is no history of allergies. He does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTSURGICAL

Dialogue:
Doctor: How did your treatment for the thrombosis go? I believe we did it on February nineteen of two thousand and seven. We finished the note the next day in order to send to your other following doctor.
Patient: The treatment went well. Thanks!

assistant: The treatment of the thrombosis was documented on 02/19/2007 and 02/20/2007.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ROS

Dialogue:
Doctor: Where are you having numbness?
Patient: In my left hand.
Doctor: And no other symptoms? Any coughing or chest pain?
Patient: No. Just that weird feeling in my left hand.
Doctor: Any visual changes or motor changes.
Patient: Nothing.
Doctor: Great. What about any phlegm or shortness of breath?
Patient: Nope.

assistant: No coughing, sputum production, dyspnea or chest pain. No vomiting or abdominal pain. No visual changes. No neurologic deficits other than some numbness in his left hand.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: How are you feeling?
Patient: I've been having a lot more joint pain lately.
Doctor: You're seventy seven, correct?
Patient: Don't remind me.
Doctor: When did you first start experiencing joint pain?
Patient: Couple years ago.
Doctor: In what ways has it worsened?
Patient: It's caused me to become less active in general. My hands and wrists aren't as mobile.
Doctor: Have you noticed any increased swelling?
Patient: No, but it's all gotten to be a little too uncomfortable.
Doctor: I see here that you take the generic of Daypro. Is that helping?
Patient: No.
Doctor: And no redness to the area, right?
Patient: No.
Doctor: Fever or chills?
Patient: I had diarrhea for a few days, but it's gotten much better. I was also having trouble holding my bladder.
Doctor: Are you going to the bathroom more often, experiencing excessive thirst, or other problems?
Patient: No. My incontinence is a bit better and so is my ankle and foot swelling.
Doctor: How has your blood sugar been?
Patient: A little better.
Doctor: Have you checked your blood pressure recently?
Patient: Not recently.
Doctor: Any new medications?
Patient: I'm back on Zoloft again because I think I might be depressed. Ever since losing most of my mobility, I haven't been feeling like my usual myself. I'm also sleeping all the time.

assistant: A 77-year-old white female who is having more problems with joint pain. It seems to be all over decreasing her mobility, hands and wrists. No real swelling but maybe just a little more uncomfortable than they have been. The Daypro generic does not seem to be helping at all. No fever or chills. No erythema. She actually is doing better. Her diarrhea now has settled down and she is having less urinary incontinence, less pedal edema. Blood sugars seem to be little better as well. The patient also has gotten back on her Zoloft because she thinks she may be depressed, sleeping all the time, just not herself and really is disturbed that she cannot be more mobile in things. She has had no polyuria, polydipsia, or other problems. No recent blood pressure checks.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Anyone in your family been sick lately?
Patient: Yes, my sister has sinus problems. She was seen today.
Doctor: Okay that means she will be treated.
Patient: Yes.
Doctor: How about other family members?
Patient: No, my mom and dad are healthy.
Doctor: Good. Good.
Patient: Hm!

assistant: The sister is in today with clinical sinusitis. Mother and father have been 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: GENHX

Dialogue:
Doctor: So, tell me what's going on with you?
Patient: Well, yesterday evening between seven or eight I developed nausea and suddenly it started hurting on the right side of my chest?
Doctor: Where exactly did it hurt?
Patient: Ah, my upper chest part and it went all around my right side till my back.
Doctor: Okay, how do you feel now?
Patient: I feel very weak and tired, don't feel like doing anything but resting.
Doctor: Any fever?
Patient: Yeah, nurse just took my temperature it was one hundred point three.
Doctor: Okay. Did you have these symptoms before?
Patient: No, first time. I never felt like this before.
Doctor: Okay. Any chills or shivering?
Patient: No.
Doctor: When was your last bowel movement?
Patient: It was yesterday.
Doctor: Did you notice any blood in your stool or any rectum bleeding?
Patient: No.
Doctor: How old are you?
Patient: I am twenty eight.
Doctor: Okay, and you had a gastric bypass surgery, one year ago.
Patient: Yes, almost one year ago. I lost about two hundred pounds after that.
Doctor: And you felt well after the surgery?
Patient: Absolutely! Until yesterday when my nausea and pain started.
Doctor: Okay.

assistant: The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago. He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back. He feels like he was on it but has not done so. He has overall malaise and a low-grade temperature of 100.3. He denies any prior similar or lesser symptoms. His last normal bowel movement was yesterday. He denies any outright chills or blood per rectum.
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: Okay, so it looks like your blood work shows that your sodium levels are very low. This could explain some of the symptoms you've been having lately.
Patient: What does that mean? Why are my sodium levels so low?
Doctor: It could be due to a number of-
Patient: Should I start eating more salt?
Doctor: Not necessarily. But I believe it's partly due to the diuretic that you've been taking these past few weeks. Your blood work also shows anemia. I'd like to start you on some iron supplements for now and get you back in for another eval. The front desk has access to your orders and they can print you out a lab slip.
Patient: Do you think the iron will help with my tiredness? I've been so exhausted and caffeine hasn't been helping one bit.

assistant: 1. Acute tiredness. 2. Anemia of unknown etiology. 3. Acute hyponatremia.
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, you are a cigarette smoker?
Patient: Yeah.
Doctor: How much do you some?
Patient: Not as much as some people.
Doctor: How much is that exactly?
Patient: Well, I probably buy a new pack once a week.
Doctor: Okay. So that is about four packs a month and fifty packs a year.
Patient: Yeah, I guess so.

assistant: 50+pack-yr cigarette use.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are you married, sir?
Patient: Yes, to my wonderful wife.
Doctor: Great, can I assume you support each other at home?
Patient: Yes, doctor, that's correct.
Doctor: Do you smoke or drink, sir?
Patient: Well, I don't smoke, and I don't do anything harder, either. But I drink just about every day.
Doctor: How much do you drink a day?
Patient: I drink maybe two or three drinks a day, so maybe four or nine a week.

assistant: He is married and has support at home. He denies tobacco and illicit drug use and drinks two to three alcoholic beverages a day and up to four to nine per week.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you know if anyone in your family has history of heart disease, stroke anything of that sort?
Patient: Let me think. You mean only blood relatives?
Doctor: Yes.
Patient: Yes. We have some of those diseases in our family.

assistant: Remarkable for coronary artery disease, stroke, and congestive heart failure.
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: What kinds of surgeries have you had in the past?
Patient: I have had a heart bypass surgery.
Doctor: Is that C A B G?
Patient: Maybe. And I have had my tonsils and appendix taken out.
Doctor: Sure. Okay.

assistant: CABG, appendectomy, tonsillectomy
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. Can you tell me more about this low back pain?
Patient: Well, I'm not as young as I used to be, I'm fifty nine.
Doctor: What set this pain off? Is there any injury?
Patient: Yes, I had a fall in the beginning of two thousand six. I slipped on a freshly waxed floor.
Doctor: What part of your lower back did you fall onto?
Patient: I fell onto my tailbone and just general lower back.
Doctor: Is this the only fall you've had?
Patient: No, I had another one in March of two thousand six.
Doctor: What happened when you fell that time?
Patient: I was trying to qualify on the gun range with a handgun, when I lost my footing.
Doctor: What made you lose your footing?
Patient: I think it was more weakness than a loss of balance.
Doctor: What treatments have you had for this?
Patient: Well, I've been to P T, and I had, um, cauterization of some of the nerves in my lower back.
Doctor: How many times have you had this cauterization done?
Patient: I've had it twice, once in October and the other in November.
Doctor: This was in two thousand eight, right?
Patient: Correct. The P T said I have low back pain and degenerative disc disease.

assistant: The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient states that this occurred in October 2008 as well as November 2008. The patient has a history of low back pain, secondary to a fall that originally occurred in 2006. The patient states that she slipped on a newly waxed floor and fell on her tailbone and low back region. The patient then had her second fall in March 2006. The patient states that she was qualifying on the range with a handgun and lost her footing and states that she fell more due to weakness in her lower extremities rather than loss of balance.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTSURGICAL

Dialogue:
Doctor: Have you ever had surgery, ma'am?
Patient: Yeah, doctor, I've had a whole lifetime worth of back surgeries.
Doctor: How many surgeries have you had?
Patient: I've had four.
Doctor: Do you know the surgeries you've had?
Patient: Actually, I have the op notes here.
Doctor: I see, you've had an anterior cervical discectomy, and fusion of C three through C seven.
Patient: Yes, I had all of those with Doctor L.
Doctor: Do you have any children?
Patient: Yes doctor, I have seven, but I had three miscarriages.
Doctor: Were any of your children born through C sections?
Patient: No, none of them were.

assistant: She has had over her over her lifetime four back surgeries and in 2005 she had anterior cervical discectomy and fusion of C3 through C7 by Dr. L. She is G10, P7, no cesarean sections.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTSURGICAL

Dialogue:
Doctor: Have you ever had any major surgeries?
Patient: I had a skin tag removed but no. No major surgeries.
Doctor: Okay.

assistant: No significant past surgical 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: GENHX

Dialogue:
Doctor: With ten being the worst pain imaginable, out of ten, how would you describe your pain today?
Patient: I'd say its about a six out of ten today.
Doctor: What makes the pain worse?
Patient: It's worse when I try to walk around on it.
Doctor: Do you have any pain at night?
Patient: No, thankfully I don't.
Doctor: How long have you been wearing that exterior knee brace?
Patient: Oh, for a little while now.

assistant: The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation. The patient does deny pain at night. The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ROS

Dialogue:
Doctor: I need to ask you a few questions.
Patient: Sure.
Doctor: Do you feel any weakness or tiredness?
Patient: No.
Doctor: Any uneasiness or illness?
Patient: No, nothing of that sort.
Doctor: Any chills or high temperature?
Patient: Nope.
Doctor: Any excessive sweating or night sweating?
Patient: Um, no.
Doctor: How about allergies, are you allergic to anything?
Patient: No, no allergies.
Doctor: Alright.

assistant: GENERAL: Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative 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: FAM/SOCHX

Dialogue:
Doctor: Do you smoke?
Patient: Yes!
Doctor: How about alcohol, do you drink?
Patient: Yes, I do.
Doctor: And how much do you drink and is it occasional or on daily basis?
Patient: Well, I love my wine, I drink about four to five glasses per day.
Doctor: Wow! That's a lot.

assistant: The patient is a smoker and drinks alcohol daily in considerable amounts.
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 important family history, any medical issues in the family?
Patient: Well, my father died of a heart attack. I don't remember how old he was, but I do remember that he had some long run heart issues.
Doctor: What about your mom?
Patient: My mom's death was a mystery for all of us. She died of some complications because of the dental procedures. So never got to know what killed her.
Doctor: Do you have kids? Are they all doing good health wise?
Patient: I have a daughter, she's healthy.

assistant: Father died of an MI at unknown age, Mother died of complications of a dental procedure. He has one daughter who is 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: CC

Dialogue:
Doctor: Hi there! How are you today?
Patient: Hi. I am not doing so well. I have had this cough and a pain in my stomach. Right here by my belly button.
Doctor: How long has this been going on?
Patient: Two days. It has been very painful.
Doctor: I would like to examine your abdomen. Is that okay?
Patient: Yes.

assistant: Cough and abdominal pain for two days.
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: Can you please confirm the medications that you have already taken?
Patient: Yeah, I just finished the course for Minocin. I also took Duraphen II D M.

assistant: Recently finished Minocin and Duraphen II DM.
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: Has anyone in your family had a history of heart disease or issues?
Patient: Well, yeah. Actually, my dad passed away due heart disease.
Doctor: Oh, I am sorry to hear that. Do you know what kind of heart problem he had?
Patient: Yeah, it is called co-
Doctor: Oh, coronary heart disease?
Patient: Yes, exactly!
Doctor: I see.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you smoke or drink?
Patient: No.
Doctor: Any drugs?
Patient: You mean like meth?
Doctor: Yeah.
Patient: No, never did it.
Doctor: Okay.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Hello, miss. How are you? What brings you to my office today?
Patient: I am doing well. Just here for a refill on my medication.
Doctor: Great. That should be easy. How has the stress management been going to control the acne?
Patient: It is going well. My husband has been on board with my meditations and yoga. He is very supportive.
Doctor: Wonderful. Are will still clean from drinking and smoking? That can interact with your medications.
Patient: Yeah I know. I don't drink or smoke.

assistant: The patient is married. She is a nonsmoker and nondrinker.