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: GENHX

Dialogue:
Doctor: Hello, miss. How are you feeling today?
Patient: Terrible. My allergies are killing me right now.
Doctor: Do you have a history of allergies?
Patient: Yeah, I do. I had them all the time when I lived in Seattle, but they got a lot worse when I moved here. I am a strong German woman and I hate how something as little as allergies gets the best of me.
Doctor: Why did you move here?
Patient: I wanted to experience different cities since I'm only twenty three.
Doctor: That sounds exciting. Back to your allergies now. Do you take any medication to relieve your symptoms?
Patient: Here's a list of past and current medications I'm taking.
Doctor: Thank you. Let me take a look. I see you took Claritin and Zyrtec in the past, correct? Did those help you?
Patient: Yeah, that's correct. They were working for a bit, but then they stopped working after a while.
Doctor: I see. Your notes say you took Allegra after, correct?
Patient: Correct. I tried out Allegra last summer, but I don't know if it was doing its job. I tried it again two weeks ago because my allergies were getting bad, but it still didn't work.
Doctor: I see. Your notes state you've tried some nasal sprays, correct?
Patient: Yeah, I did. I wanted to see if they would work.
Doctor: Were you prescribed these nasal sprays?
Patient: Nope. I bought them at my local pharmacy.
Doctor: Sounds good. I'm looking at your medical history, and it sates here you have asthma too, correct?
Patient: Yeah, I've had it for a long time, but it hasn't gotten worse.
Doctor: I see. Do you think you need any medication to help alleviated your asthma?
Patient: No. It doesn't bother me as much as my allergies.

assistant: This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here. In the past, she has tried Claritin, and Zyrtec. Both worked for short time but then seemed to lose effectiveness. She has used Allegra also. She used that last summer and she began using it again two weeks ago. It does not appear to be working very well. She has used over-the-counter sprays but no prescription nasal sprays. She does have asthma but doest not require daily medication for this and does not think it is flaring up.
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: How are you doing young man?
Patient: I'm good. Thank you.
Doctor: Let's see how your chest is doing.
Patient: Okay.
Doctor: Chest measurements look nice. No issue there. The outline also looks great. Also, there is no hunchback?

assistant: CHEST: Normal AP diameter and normal contour without any kyphoscoliosis.
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 see here that Doctor-
Patient: Yes, Doctor X referred me. My thyroid is an absolute mess. I have never been in so much pain in my seventy one years.
Doctor: I'm so sorry to hear that. I hope we're able to get you the care that you need.
Patient: I've been coughing up a storm. It's gotten to be way too enlarged.
Doctor: It's good that you're here today to get the surgery rolling.
Patient: I signed the paperwork and everything.
Doctor: I'll go over the risk and benefits one more time. Any questions for me?
Patient: When is the earliest I can get this done again?
Doctor: Given your symptoms, I'd like to get you in in the next few days.

assistant: Briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter. She presented now after informed consent for the procedure, understanding the inherent risks and complications and risk-benefit ratio.
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 any medications?
Patient: No, I am not allergic to any drugs.
Doctor: Okay. Are you sure?
Patient: Yes.

assistant: No drug allergies.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ALLERGY

Dialogue:
Doctor: I see here that you're allergic to grapefruit and peanuts. Do you happen to be allergic to any medications you've taken in the past?
Patient: Nah, just allergic to grapefruit and peanuts.
Doctor: Gotcha. Do you carry an Epi pen around with you?
Patient: I try to bring it with me everywhere I go.

assistant: There are no known 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: So, tell me about your family, any illness or anything that runs in the family.
Patient: Um, not that I know of.
Doctor: Okay.

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: PASTMEDICALHX

Dialogue:
Doctor: Any medical issues in the past?
Patient: No, I have a very clean history.
Doctor: That's good for you. Any kind of surgery or hospitalization?
Patient: No.

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: FAM/SOCHX

Dialogue:
Doctor: Let's talk a little bit about your family, okay?
Doctor: Does anyone in your family had any medical issues?
Patient: Yeah, my parents died of cancer.
Doctor: Which cancer? How old were they?
Patient: I don't know which cancer they had, but my mother was forty two and dad was sixty two.
Doctor: Who else is there in the family?
Patient: Oh, I have a big family. I have four sisters, one brother and two half brothers. One of my half brother's has asthma.

assistant: Mother died age 42 of unknown type cancer. Father died age 62 of unknown type cancer. 4 sisters, one brother and 2 half-brothers. One of the half-brothers has 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: FAM/SOCHX

Dialogue:
Doctor: So, tell me something, does asthma run in your family?
Patient: No, I think I am the only one who has it. Even my parents were surprised when I developed it, as no one else has it.
Doctor: Yeah, it happens.

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

user: Section: GENHX

Dialogue:
Doctor: Welcome in, sir. I am Doctor Gray.
Patient: Thank you. It's nice to meet you.
Doctor: What is your past medical history?
Patient: I had surgery on my shoulder thirteen years ago and after the surgery I lost my sense of smell. I still can't smell. I also can't see very well in my right eye.
Doctor: How old are you?
Patient: I am seventy six.
Doctor: Do you get headaches?
Patient: No.
Doctor: Do you have any nasal drainage?
Patient: No.
Doctor: Do you ever experience any weakness or numbness throughout or localized to an area of the body.
Patient: No.
Doctor: Have you had any resent weight loss?
Patient: No.

assistant: 76 y/o male suddenly became anosmic following shoulder surgery 13 years prior to this presentation. He continues to be anosmic, but has also recently noted decreased vision OD. He denies any headaches, weakness, numbness, weight loss, or nasal discharge.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Good afternoon, sir. Did you see the nurse already?
Patient: Yes, I just saw her.
Doctor: Great, you're seventy eight years old, correct?
Patient: Yes, I'm not as young as I used to be.
Doctor: Who is? What seems to be the problem today, sir?
Patient: I have right hand pain, and it's been there for a while now.
Doctor: Are you having numbness sir?
Patient: Yes, and I can't move it very well, either.
Doctor: Which fingers are you having these symptoms in?
Patient: Well, I told you it's all in the right hand, but it's in the index and middle fingers.
Doctor: Are your fingers catching?
Patient: What does that mean, doctor?
Doctor: Are you having any problems extending your fingers?
Patient: Yes, they seem to lock up when I try to extend my fingers.
Doctor: Have you seen another doctor for this?
Patient: Yes, I had an E M G and it showed, um, carpal tunnel on both hands.
Doctor: It's in both hands, but the right is worse than the left, correct?
Patient: Yes, that's correct.
Doctor: What treatments have you had for this?
Patient: I only had an injection so far.
Doctor: Did this help at all?
Patient: Well, some, but it was really only temporary relief. Is there surgery for this?
Doctor: Yes, I think you'd be a good candidate for surgery.
Patient: What are the risks of infection from the surgery?
Doctor: It's less than one percent. We use prophylactic antibiotics to control for infection the entire time.
Patient: Even though it's on my hand, will I be asleep for this procedure?
Doctor: Yes, you won't feel a thing.
Patient: Okay, yes. I'd like to do the surgery.

assistant: This is a 78-year-old male who is complaining of right hand pain and numbness with decreased range of the middle index finger and right middle finger complaining of catching and locking. The patient was diagnosed with carpal tunnel syndrome on bilateral hands the right being worse than the left. He had positive EMG findings as well as clinical findings. The patient did undergo an injection, which only provided him with temporary relief and is for this reason, he has consented to undergo the above-named procedure. All risks as well as complications were discussed with the patient and consent was obtained.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Hi are you married?
Patient: Yes, I am.
Doctor: Do you have kids?
Patient: Yes, I had a son, but unfortunately, he died in a car accident. It was five years ago.
Doctor: Where do you work?
Patient: I work in a pharmaceutical company as a salesperson.
Doctor: Do you smoke or drink or at any time tried any illicit drug?
Patient: No, I've never smoked. I have tried a beer once, but I never liked it.
Doctor: What about drugs?
Patient: No, never did that.

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

user: Section: ASSESSMENT

Dialogue:
Doctor: Are you going to visit rehab?
Patient: Yes, what choice do I have?
Doctor: Yes, please do visit Mercy Manor for P T and Rehab.
Patient: Yes, I will.
Doctor: That will help your right side hip pain.
Patient: I think so too.

assistant: Right hip pain, the patient to undergo physical therapy and rehabilitation at Mercy Manor.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: IMMUNIZATIONS

Dialogue:
Doctor: Can you tell me about your Immunizations?
Patient: Yeah, I had them all.
Doctor: Good, looks like you are up to date.

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

user: Section: GENHX

Dialogue:
Doctor: Welcome back to the clinic. How are you feeling today?
Patient: Thank you. I am doing better.
Doctor: It looks like we are following up on your severe osteoarthritis in both knees. And you also have been experiencing some flexion contracture limitations.
Patient: Um hum.
Doctor: How is your physical therapy going?
Patient: It is going really well. She kicks my butt but it seems to be helping. Doing my exercises at home is really helping.
Doctor: Were you not doing them in the beginning?
Patient: No, I wasn't. She got on me to start doing them and I have definitely seen the difference.
Doctor: Have you experienced any worsening of pain since you were last seen?
Patient: Well, the right knee is worse than the left? It mostly hurts after physical therapy.
Doctor: Can you describe what the pain feels like?
Patient: It feels achy.
Doctor: Is it a continuous pain, or?
Patient: No. It is not all the time. Every once and a while. It feels stiff all the time.
Doctor: Any weakness or instability?
Patient: No.
Doctor: Any burning sensations associated with the pain?
Patient: No.
Doctor: How long have you been dealing with this?
Patient: Several months.
Doctor: Have you had any trouble sleeping?
Patient: No. When I sit down or lie down at night there's no pain.
Doctor: So, the pain is when you are weight bearing, right?
Patient: Yeah. And it hurts when I move around. It makes it difficult to do things.
Doctor: Have you noticed any pain with the cold weather change?
Patient: No, I have not noticed anything.
Doctor: I am just going to take a look here.
Patient: Okay.
Doctor: I don't see any swelling or redness. And I don't feel any warmth coming from the area. Have you noticed any of these symptoms?
Patient: Nope.
Doctor: Any radiating pain through the knees here?
Patient: No.
Doctor: Any pain any where else in the body?
Patient: No, just the knees.
Doctor: So, no pain in the hips or back?
Patient: Nope.

assistant: The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great. Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left. Pain: Localized to the bilateral knees right worse than left. Quality: There is no swelling, no redness, or warmth. The pain is described as aching occasionally. There is no burning. Duration: Months. Associated symptoms: Includes stiffness and weakness. There is no sleep loss and no instability. Hip Pain: None. Back pain: None. Radicular type pain: None. Modifying factors: Includes weight bearing pain and pain with ambulation. There is no sitting, and no night pain. There is no pain with weather change.
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, what is going on?
Guest_family: She was doing well until this morning, but now she can barely move her right arm and is having speech issues. She can't seem to comprehend words. I think it is a stroke.
Doctor: We see this a lot at A B C Medical Center. I am glad you came. You just saw Doctor H, right?
Guest_family: Yes. We did a C T head scan and labs.
Doctor: Okay. Where is she living? With you?
Guest_family: No. She is at the Life Care Center.
Doctor: Ma'am, do you have headache or chest pain?
Patient: What? What? Huh?
Guest_family: She has not complained of anything like that.
Doctor: Ma'am. Do you have vision issues?
Patient: What? I can see. Of course I can see.
Doctor: Any shortness of breath?
Guest_family: She is breathing fine.
Doctor: Have your symptoms improved at all? Or have they worsened since this morning?
Guest_family: No. They have stayed constant.

assistant: The patient was doing well until this morning when she was noted to have right-sided arm weakness with speech difficulties. She was subsequently sent to ABC Medical Center for evaluation and treatment. At ABC, the patient was seen by Dr. H including labs and a head CT which is currently pending. The patient has continued to have right-sided arm and hand weakness, and has difficulty expressing herself. She does seem to comprehend words. The daughter states the patient is in the Life Care Center, and she believes this started this morning. The patient denies headache, visual changes, chest pain and shortness of breath. These changes have been constant since onset this morning, have not improved or worsened, and the patient notes no modifying factors.
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 think you have a muscular strain.
Patient: Yeah.
Doctor: So right side shoulder strain and maybe a little bit of nerve compression.
Patient: Oh really!
Doctor: Maybe. I will do further evaluation and treatment.
Patient: Okay.

assistant: Right shoulder pain, most likely secondary to muscular strain. He does have a very mild evidence of impingement.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Can you tell me more about your daughter, ma'am?
Guest_family: Sure, well she's fourteen now, um, she's right handed, and she just started high school.
Doctor: Has she ever had surgery?
Guest_family: Yeah, she had an, um, lipomyomeningocele repair when she was about three days old, and then again when she was three and a half years old.
Doctor: When was her last surgery?
Guest_family: Um, it was in March of nineteen ninety five.
Doctor: How did she do following the second surgery?
Guest_family: She did well, honestly.
Doctor: So, what brings you in for a visit today?
Patient: Well, I've been having some leg pain on the side of my legs.
Doctor: How long have you had this pain?
Patient: It's been several months at this point.
Doctor: When is your pain the worst?
Patient: Um, it's the worst at night, I have to take medicine for the pain.
Doctor: What do you take?
Guest_family: She takes Advil, Motrin, and Tylenol P M.
Doctor: Wow, that's a lot. Looks like you have some patch sensory loss in the L four to S one region. Are you going to the bathroom regularly?
Patient: Yeah, there's no problems there. I do have some loss of feeling in my big toe and calf though.

assistant: Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. The last surgery was in 03/95. She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM. Denies any new bowel or bladder dysfunction or increased sensory loss. She had some patchy sensory loss from L4 to S1.
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: DISPOSITION

Dialogue:
Guest_clinician: How is the patient's condition now?
Doctor: Well, he has improved clinically but would require acute care.
Guest_clinician: Oh, I see.

assistant: Clinically improved, however, requiring acute 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: FAM/SOCHX

Dialogue:
Doctor: Let's talk about your family's medical history.
Patient: Hm, well both my father and my brother had colon cancer. My daughter was detected with breast cancer.
Doctor: Do you remember what her age was?
Patient: Yeah, she was forty.
Doctor: I see. Anything else?
Patient: Well, I have a heart condition and high blood pressure. I also had a stroke.
Doctor: Okay.

assistant: Positive for heart disease, hypertension and cerebrovascular accidents. Family history is positive for colon cancer affecting her father and a brother. The patient has a daughter who was diagnosed with breast cancer at age 40.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ROS

Dialogue:
Doctor: Any fever?
Patient: No.
Doctor: No nausea and vomiting or black stool? Did you notice any blood in your stools?
Patient: Nope, nothing like that.
Doctor: Did you notice any blood in urine or painful urination?
Patient: No.
Doctor: Okay, any chest pain?
Patient: Um, no.
Doctor: Any shortness of breath, cough or cold like symptoms?
Patient: Nope.
Doctor: No diabetes or thyroid problem, right?
Patient: Absolutely not!
Doctor: Looks like you have no history of C V A or stroke.
Patient: Correct.
Doctor: Everything else looks fine.
Patient: Cool.
Doctor: Your eyes, nose, and throat look good.

assistant: CONSTITUTIONAL: No fever. ENT: Not remarkable. RESPIRATORY: No cough or shortness of breath. CARDIOVASCULAR: The patient denies chest pain. GASTROINTESTINAL: No nausea. No vomiting. No history of GI bleed. GENITOURINARY: No dysuria. No hematuria. ENDOCRINE: Negative for diabetes or thyroid problems. NEUROLOGIC: No history of CVA or TIA. Rest of review of systems is not remarkable.
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 doing miss? How are your sugar numbers coming along?
Patient: I'm doing good. Thank you. Sugar has consistently been one hundred and thirty five or under it.
Doctor: How are you checking it?
Patient: I have a glucose monitor at home I'm using that only.
Doctor: Nice. Did you eat anything in the morning today?
Patient: No, I'm fasting for my test.
Doctor: Okay, let's see. We have an Accu Chek here in our office. I will do a quick sugar test for you, and this will be a fasting sugar test. It will be just a quick prick on your finger.
Patient: Don't worry doctor. I'm used to poking my finger all the time.
Doctor: Let's see what we got here. Your reading says one hundred and twenty. I will write it down for my record. Are you being active?
Patient: Yes, I'm exercising as a rule three times every week. I don't miss it.
Doctor: Do you feel any tingling or numbness or any kind of cramps?
Patient: Nope.
Doctor: Any kind of blurry vision?
Patient: Nope.
Doctor: Any weight loss?
Patient: Not that I notice.

assistant: Overall, she has been doing well. Her blood sugars have usually been less than or equal to 135 by home glucose monitoring. Her fasting blood sugar today is 120 by our Accu-Chek. She is exercising three times per week. Review of systems is otherwise 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: DIAGNOSIS

Dialogue:
Doctor: How did your last visit go with the cardiologist?
Patient: Good.
Doctor: It looks like they diagnosed you with sick sinus syndrome. Do you have any questions about this new diagnosis?
Patient: No, she explained everything to me. I'm planning to follow-up with her in the next two weeks.
Doctor: Great. So it looks like your past medical history is the same? Nothing new other than the sick sinus syndrome.

assistant: Sick sinus syndrome. The rest of her past medical history remained the same.
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 Mister J, where do you stay?
Patient: Oh, I stay at a care facilit. It's very near to your clinic. Have you heard about this place called South Valley Care Center?
Doctor: Oh yes, I have heard of it.

assistant: The patient has been residing at South Valley Care Center.
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: How are you Mister James?
Patient: I have been better!
Doctor: Oh, tell me what's going on with you?
Patient: I have this leg pain on my left side.
Doctor: Hm, left leg pain?
Patient: Yeah.

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

user: Section: ALLERGY

Dialogue:
Doctor: Have you ever had an allergic reaction to drugs you've taken in the past?
Patient: More than once. I've reacted poorly to sulfa drugs, penicillin, and some mycins. I also think I'm allergic to contrast medium.

assistant: She had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins.
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: Hey, do you smoke cigarettes?
Patient: Yes I do smoke. Do you?
Doctor: Nope. Are you planning on quitting?
Patient: No, I just smoke one pack per day, it's not bad.
Doctor: Oh my God. No. It is bad. You should think about quitting.
Patient: Okay I will think about it.
Doctor: Where do you work?
Patient: I work at local christmas tree farm.

assistant: The patient works at a local Christmas tree farm. He smokes cigarettes approximately one pack per day.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are you still working?
Patient: Retired some time ago.
Doctor: What was your profession?
Patient: I used to work at a car repair shop called Champion Automotive Company.
Doctor: Nice. How did you enjoy the work?
Patient: I liked it a lot, but there came a time where I knew it was the end of the road for me. I'm really enjoying retirement.
Doctor: I bet. I have cousin who owns a car repair shop. He's almost always busy.
Patient: Yeah, it can be a lot sometimes.
Doctor: Any smoking, drinking, or hard drugs?
Patient: I can confidently say no to each one.
Doctor: Great to hear.

assistant: Retired employee of Champion Automotive Co. Denies use of TOB/ETOH/Illicit 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: PASTMEDICALHX

Dialogue:
Guest_clinician: Do you have his full medical history?
Doctor: Yes, I confirmed with his wife. He had a CABG done in ninety one. He has a history of radical prostate cancer for which he underwent a radical prostatectomy and nephrectomy.
Guest_clinician: Any additional surgeries?
Doctor: Yes. He had lumbar surgery twice before. He suffered from lumbar stenosis many years ago in the sixties and seventies. He's actually due for another lumbar surgery with Doctor Y. He takes Percocet daily for his back pain. He also has a history of hypertension and hyperlipidemia.
Guest_clinician: I think I got it all down.

assistant: Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia. Note that due to back pain, he had been taking Percocet daily prior to his hospitalization.
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 morning, sir.
Patient: Good morning, doctor.
Doctor: Before we begin, have you ever had surgery?
Patient: Yes, I had a vasectomy some time ago.

assistant: Vasectomy.
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: Okay, so let's go over your medications. I'd like you to take these to help your muscle spasms.
Patient: Sounds good.
Doctor: I've prescribed eight hundred milligrams of Ibuprofen to be taken every eight hours as needed along with Tylenol number three every six hours as needed.
Patient: What does the number three stand for?
Doctor: Tylenol number three is combined with Codeine.
Patient: Okay, I see.
Doctor: And finally, I'm prescribing Methocarbamol seven fifty milligrams which needs to be taken four times a day for maximum relief. Do you have any questions for me?
Patient: No, I think you answered them all.

assistant: Tylenol #3 q6h prn, ibuprofen 800 mg q8h prn, methocarbamol 750 mg qid.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Hi, how's it going?
Patient: Not too bad, can't complain.
Doctor: It looks like the weather's been warming up, which is nice.
Patient: Yeah, I can't wait to spend some time with my kids this afternoon.
Doctor: Aw, how many kids do you have?
Patient: Two.
Doctor: And are you single, dating, married?
Patient: I've been married to my wife for about ten years now.
Doctor: Congratulations! That's a decade, my friend.
Patient: Hah, it sure is.
Doctor: Are you from the area?
Patient: I was actually born in Oklahoma.
Doctor: How long-
Patient: Moved up here in O seven.
Doctor: Awesome. I moved here in O nine, so two years after you.
Patient: No way! How funny. Where from?
Doctor: I'm originally from Kentucky. And I have to do the routine ask, but any drinking, smoking, or illicit drug use?
Patient: No to all of the above.
Doctor: Got it.

assistant: No tobacco, alcohol or illicit drug use. Patient is born and raised in Oklahoma . No known exposures. Married with 2 children.
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: Looks like the nurse came in and asked you everything. Ah, she has everything documented here, but I will ask one more time. So, tell me, where do you live?
Patient: Oh, it's a senior citizen house. They have many nursing aids there.
Doctor: Do you smoke?
Patient: No.
Doctor: Do you work?
Patient: Ah, right now I can't because of this disability, but I used to work as the security guard.

assistant: He does not smoke. He lives in a senior citizens building with daily nursing aids. He previously was a security guard, but is currently on disability.