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: What is up with your teeth man? It's been giving you problems huh?
Patient: Yes, yes, many, many problems. Firstly, they pulled out so many teeth and now I have this bad tooth problem.
Doctor: Oh, so this is new?
Patient: Yes, it's a new pain. Right now it has been going on for three days on left side's upper and lower teeth.
Doctor: Then why didn't you go and visit your regular dentist?
Patient: I would have but I have missed so many appointments that they now do not allow me to schedule regular appointments. So they put me on a standby appointment now.
Doctor: Oh I am sorry.
Patient: It is okay.
Doctor: Okay any other problems or any other complaints?
Patient: No.
Doctor: How about any recent illnesses or injuries?
Patient: No, no illness whatsoever.
Doctor: Do you have any medicine at home for pain?
Patient: Yes I have OxyContin and Vicodin at home. I use it for my knee pain. But I want more pain medicines. I do not want to use up that medicine for my toothache.
Doctor: Okay I understand. How old are you again?
Patient: I am twenty nine.

assistant: This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled. Complains of new tooth pain. The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days. The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only. The patient denies any other problems or complaints. The patient denies any recent illness or injuries. The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.
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's your jaw doing?
Patient: The pain seems to have gotten worse.
Doctor: Do you mind if I take a look?
Patient: Sure. Ow, ow, ow. That's the spot that hurts the most. What's causing it?
Doctor: It's hard to say, but I'm thinking it could be T M J. I'd like to get you in to see a T M J specialist.

assistant: Jaw 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: MEDICATIONS

Dialogue:
Doctor: Are you taking Citalopram for depression?
Patient: Yes, I take it once a day.
Patient: It is ten M G tablet.
Doctor: Is that so?
Patient: Yes.
Doctor: What do you take for pain?
Patient: Just Tramadol as needed.

assistant: Citalopram 10mg once daily for depression; low dose tramadol PRN pain.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: What is your family health history?
Patient: My mom and dad are both diabetics. My mom has high blood pressure. My brother is having some issues with his liver.

assistant: Mother with diabetes and hypertension. Father with diabetes. Brother with cirrhosis (etiology not documented).
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 about your family?
Patient: I have or had two sons both born normally without any complications.
Doctor: Why did you say had?
Patient: One of my sons was a heavy smoker, he uses to smoke a whole packet or more in a day. We tried everything possible, but he just couldn't quit. He died of clots.
Doctor: Does anyone in your family like parents or siblings had any medical issues?
Patient: Yes, my father had heart related issues, he died in his sixties, my mother died of colon cancer. I also have a sister but I don't think she has any issues.

assistant: Her father died with heart disease in his 60s and her mother died of colon cancer. She has a sister who she believes is probably healthy. She has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy. She has two normal vaginal deliveries.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you smoke cigarettes?
Patient: Yes.
Doctor: How about alcohol?
Patient: No, I don't consume alcohol.
Doctor: Okay. And any history of using drugs like marijuana or stuff like that for fun?
Patient: No.

assistant: Active smoker. Does not consume alcohol. No history of recreational 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: Are you married, sir?
Patient: No divorced. I live a lone.
Doctor: What work do you do?
Patient: I am a retired postal worker.
Doctor: Do you have kids?
Patient: Yes, I have three of my own and seven grandkids.
Doctor: Do you smoke cigarettes?
Patient: Yes I do.
Doctor: How much and what kind?
Patient: I keep changing the brands but Newport, one pack a day.
Doctor: Okay. How about alcohol or drugs like substance abuse?
Patient: No drugs but I drink occasionally depending on the company.
Doctor: How long have you smoked?
Patient: Thirty years now.

assistant: Divorce and live alone, retired postal worker, has 3 children, 7 grandchildren. He smokes 1 pack a day of Newport for 30 years and is a social drinker. He denies any 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: CC

Dialogue:
Doctor: Hello! How are you doing?
Patient: Hello Doctor! I am good.
Patient: I am here today for my follow-up, as suggested.
Doctor: Has it been a month already?
Patient: Yes, seeing you after a month.

assistant: One-month followup.
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: Just to debrief, we will rule out angina related heart problems while evaluating your jaw pain.
Patient: Oh can that be related to each other?
Doctor: Yes they might be.
Patient: What else?
Doctor: Pardon?
Patient: I am asking anything else?
Doctor: We have discussed this before, but keep track of your high cholesterol and hypothyroid.

assistant: 1. Jaw pain, sounds musculoskeletal. We will rule out angina equivalent. 2. Hypercholesterolemia. 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: GENHX

Dialogue:
Doctor: Hello, sir. How are you feeling today?
Patient: Very itchy. I just keep scratching myself.
Doctor: Oh, wow. I can see the rashes all over your arms. Are there rashes anywhere else?
Patient: Yeah, it's all over my back and stomach.
Doctor: I see it on your torso. When did this all start?
Patient: I woke up this morning and started itching my back. After a few minutes, I noticed the rash was on my arms, chest, back, and stomach areas.
Doctor: I'm going to take a look at the rashes and the rest of your body.
Patient: Sounds good.
Doctor: It looks like your face and lips are not swollen. Could you say ah for me?
Patient: Ah.
Doctor: It looks like your tongue isn't swollen either.
Patient: That's good to hear.
Doctor: Have you been feeling a shortness of breath, wheezing, or other related symptoms?
Patient: Not that I know of.
Doctor: Sounds good. I wonder why this happened. Did you do anything the night before?
Patient: Uh. A few days ago, I was working and had to remove some insulation. Other than that, I don't know what else could have given me these rashes.
Doctor: I see. Do you remember being itchy after that? Did you try any new foods?
Patient: Nope I was not itchy. Also, my diet has been the same.
Doctor: Are you taking any new medications?
Patient: I haven't.
Doctor: You don't recall being exposed to any other substances?
Patient: Not that I know of.

assistant: This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. No facial swelling. No tongue or lip swelling. No shortness of breath, wheezing, or other associated symptoms. He cannot think of anything that could have triggered this off. There have been no changes in his foods, medications, or other exposures as far as he knows. He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you have any family medical history of migraines?
Patient: I know that my brother has them too. Mom, do you know if anyone else gets them?
Guest_family: Your grandfather had migraines.
Doctor: Okay.

assistant: There is a history of migraine in the family. The condition affects the patient's brother and maternal grandfather.
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 do you do for work?
Patient: I am retired now. I was a school teacher.
Doctor: Are you a smoker?
Patient: Yes.
Doctor: How much do you smoke per day?
Patient: I would say about a half to a full pack a day.
Doctor: How long have you been a smoker.
Patient: Probably sixty years.

assistant: retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ALLERGY

Dialogue:
Doctor: Are you allergic to anything?
Patient: No, I am not.
Doctor: Are you sure? Penicillin or sulfa?
Patient: Nope nothing.
Doctor: That's good.

assistant: Denies any 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: ROS

Dialogue:
Doctor: Hi there, sir! How are you doing today?
Patient: I feel out of it.
Doctor: Have you been using any substances?
Patient: I did a little heroin and some coke earlier today. I still feel high.
Doctor: Okay. Any shortness of breath, chest pain, abdominal pain or back pain?
Patient: No.
Doctor: Are you having any headaches, hallucinations or visual disturbances?
Patient: No.
Doctor: Do you have any open sores or wounds?
Patient: No.

assistant: The patient states that he did use heroin as well as cocaine earlier today and feels under the influence. Denies any headache or visual complaints. No hallucinations. No chest pain, shortness of breath, abdominal pain or back pain. Denies any abscesses.
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 had any surgical procedures done?
Patient: Yes, in fact I had a hysterectomy back in March of ninety nine. I believe it was done on the twentieth of the month.
Doctor: Got it.

assistant: Hysterectomy (3/20/99).
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:
Patient: You know Doctor, I am widowed for eighteen years now. Never remarried, I live by myself in my house.
Doctor: Oh okay, are your still working?
Patient: No, I use to run a restaurant, but now retired.
Doctor: Hm. And you smoke cigarettes?
Patient: No, I don't! Never liked the smell.
Doctor: How about alcohol?
Patient: No, I don't drink either.

assistant: She is a nonsmoker and nondrinker. She has been widowed for 18 years. She lives alone at home. She is retired from running a restaurant.
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 old are you, sir?
Patient: I'm sixty five years old.
Doctor: Are you right handed or left handed?
Patient: I'm right handed.
Doctor: When was your last stroke?
Patient: Well, it was on January seventeenth. I had these episodes where I was like always so confused and looks like I lost everything. All my memory and everything. And then they did a scan. It was verified that I was having a stroke on the same day.
Doctor: Did they put you on some medications?
Patient: They gave me an anticonvulsant and aspirin.
Doctor: Are you taking them regularly?
Patient: There have a few times like one or two days that I forgot to take my, uh, dyphenhydramine, but even when I'm taking it regularly, I'm still having all those symptoms or forgetfulness, confusion, and everything.
Doctor: Do you feel anything else along with these episodes like a urine urgency, tendency to bite your tongue, headaches, any visual change, or your heart is beating very fast? Any kind of weakness or numbness or shortness of breath?
Patient: No nothing else, just the confusion and forgetfulness.
Doctor: How frequent are these episodes?
Patient: Well, they occur like two or three times in a week. Each one of the episodes lasts for like one or two minutes.

assistant: This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The "stroke" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times 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: Any medical disorders in the family?
Patient: Yeah, my father had a special kind of tumor, which doctors said is very rare.
Doctor: Do you know the name of the tumor?
Patient: I don't remember the exact name of the disease, but it was a big name and it started with something with V.

assistant: Father with Von Hippel-Lindau 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: PASTMEDICALHX

Dialogue:
Doctor: Do you have any major medical conditions that I should know about?
Patient: Actually, I have a whole list of conditions. I have them written down here.
Doctor: Thank you, so I see congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, and a history of paroxysmal atrial fibrillation. Oh, and azotemia.
Patient: Yes, I told you I have a lot going on.
Doctor: Are you taking any medications?
Patient: Well, they wanted me to take Coumadin but I had, um, a subdural hematoma so they would let me.
Doctor: I see, what about any neurological or psychological conditions?
Patient: Well, I have depression, and I've had panic attacks while taking Doxepin before.
Doctor: I see here that you also have perioperative anemia, does that sound familiar?
Patient: Yes, another doctor told me about that.
Doctor: Do you have any other symptoms you'd like to report today?
Patient: Um, I'm having some difficulty swallowing.

assistant: Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation. Remote history of subdural hematoma precluding the use of Coumadin. History of depression, panic attacks on Doxepin. Perioperative anemia. Swallowing difficulties.
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: Doctor Shami, can you please take down the notes as I examine the patient?
Guest_clinician: Sure.
Doctor: Can you put the heading as cervical lymph nodes.
Guest_clinician: Okay.
Doctor: I am going to check for any swelling in your neck okay? Can you look down?
Patient: Okay.
Doctor: Alright, I do not feel anything here. Can you look up?
Patient: Sure.
Doctor: No palpable nodes here. None of the lymph nodes are enlarged or have any swellings.
Guest_clinician: So, no lymph adenopathy?
Doctor: Yeah.

assistant: LYMPH: Cervical lymph nodes. No lymphadenopathy.
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: You have chronic pain?
Patient: Yes I do.
Doctor: You use tobacco also?
Patient: Yes.
Doctor: And you have a history of hepatitis C, right?
Patient: That sounds right.
Doctor: Okay.
Patient: Yeah.

assistant: 1. Chronic pain. 2. Tobacco use. 3. History of hepatitis C.
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 close to the office, or did you have to drive a long way here?
Patient: I live right around here, I'm a local girl.
Doctor: Good, are you working right now?
Patient: Yes, doctor, I work full time.
Doctor: That's good, sometimes it's nice to stay busy. Is there any history of drug or alcohol abuse I should know about?
Patient: No, absolutely not, doctor.

assistant: The patient lives here locally. She does not report any significant alcohol or illicit drug use. She works full 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: GENHX

Dialogue:
Doctor: How are you, Mary?
Patient: I am okay, I have got this ulcer on my right hip again.
Doctor: Oh, is it like the one you got last time?
Patient: Pretty much.
Doctor: Oh, I remember that one. It took almost three treatment cycles to get resolved.
Patient: Yeah. They keep saying I have some hidden split in my spine still.
Doctor: Yeah, it looks like you have residual spina bifida.
Patient: I am just so frustrated sitting in my wheelchair. I am spending around sixteen hours a day in this wheelchair.
Doctor: I think, that is the reason you developed this pressure ulcer. It appears to be on the right trochanter area. In simple terms you have developed a pressure sore on the outer part of your hip.
Patient: Yeah, I recently celebrated my thirtieth birthday just sitting in my wheelchair the whole day.
Doctor: Oh, I am sorry dear. So, how long since you have had this ulcer?
Patient: It's been several weeks, so I thought I should get it checked.
Doctor: Yeah, good thing you came. We need to treat it. Did you experience any chills or fever?
Patient: No.
Doctor: Any other symptoms?
Patient: No.

assistant: This is a 30-year-old female patient presenting with the above chief complaint. She has a history of having had a similar problem last year which resolved in about three treatments. She appears to have residual from spina bifida, thus spending most of her time in a wheelchair. She relates recently she has been spending up to 16 hours a day in a wheelchair. She has developed a pressure decubitus on her right trochanter ischial area of several weeks' duration. She is now presenting for evaluation and management of same. Denies any chills or fever, any other symptoms.
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 history of heart disease that you know of?
Patient: Nope, nothing like that.
Doctor: How about diabetes?
Patient: No, there's no sugar here that I know of.
Doctor: Good, and how about your lungs? Do they work well.
Patient: Absolutely, they're in great shape. There's nothing like that here.

assistant: Denies diabetes, cardiovascular disease, or pulmonary 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: IMAGING

Dialogue:
Doctor: Your chest x ray showed diffuse pulmonary edema. This means that you have fluid in your lungs. That would explain your chest pain and the difficulies with your breathing. I would like to start you off with a course of antibiotics to prevent any possible infection. I will also send in a prescription for Furosemide. It will reduce the fluid accumulation in your lungs. Do you have any questions?
Patient: When should I start to feel better?
Doctor: You should start to feel better within three to five days.

assistant: Chest x-ray revealed a diffuse pulmonary 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: ROS

Dialogue:
Doctor: Any headaches?
Patient: No.
Doctor: Any history of seizures or epilepsy?
Patient: No.
Doctor: Any sudden loss of consciousness or have you blacked out?
Patient: Um, no.
Doctor: Any weakness? Feeling any tremors in your body?
Patient: No, nothing like that.
Doctor: Any history of stroke or any brain related condition?
Patient: No, no such history.

assistant: NEUROLOGIC: Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor. No history of strokes, no history of other neurologic conditions.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are there any known disease running in your family?
Patient: My dad has high blood pressure, and he takes medication for it. He is now eighty two years old. He had a stroke around two years ago. This was his second stroke. First one he had when he was forty five.
Doctor: What about your mom? How old is she?
Patient: My mom is eighty years old. She does have sugar issues.

assistant: Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80.
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 currently living alone?
Patient: Yep. Just me, myself, and I.
Doctor: What do you do for a living?
Patient: I've been working as a plumber for the last five years.
Doctor: Nice. Where do you work?
Patient: Mostly in the city.
Doctor: Do you drink, smoke, or do injection drugs?
Patient: I drink and smoke here and there, but I've never tried hard drugs.
Doctor: Any recent travel?
Patient: I was in Mexico earlier this year.
Doctor: That sounds nice. How was your trip?
Patient: Relaxing. Much needed.
Doctor: Great to hear. I have a few more questions I need to ask so bear with me. How is your sexual history? Are you sexually active?
Patient: I'm sexually active with women, but my sex life isn't as good as it was in Japan. Over there, I would mix and mingle with prostitutes.
Doctor: Did you use protection?
Patient: I don't really remember.
Doctor: Have you been tested for S T D's?
Patient: Yep. I'm negative for right now.
Doctor: Have you ever been incarcerated?
Patient: Nope.
Doctor: One last question. Have you ever been in need of a blood transfusion?
Patient: No, thank God.

assistant: Patient is single and he lives alone. He is heterosexual and has a history of sexual encounter with prostitutes in Japan. He works as a plumber over the last 5 years. He smokes and drinks occasionally and denies any history of IV drug use. No blood transfusion. No history of incarceration. Recently traveled to Mexico .
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, champ, how you holding up?
Patient: Good afternoon, Doctor, I have a lot of lower back pain.
Doctor: Oh no, before we begin, how old are you, sir and which hand do you write with?
Patient: I'm seventy five now. Right.
Doctor: Great, so tell me, how long have you had this lower back pain?
Patient: It's been about ten days now.
Doctor: Have your symptoms improved at all since they began?
Patient: No, they keep getting worse.
Doctor: Does the pain radiate into your legs?
Patient: Yes, it started radiating down my right leg three days after the lower back pain began, and then the left leg three days after the right. The next day I could barely walk, the pain was so severe.
Doctor: Do you remember the initial date of the beginning of your low back pain?
Patient: Um, it was on December third nineteen ninety five.
Doctor: Have you seen another doctor for this pain?
Patient: Yes, I saw my local physician, um, it was on December eleventh, but he wasn't able to pinpoint what was going on.
Doctor: What kind of treatments did he recommend?
Patient: He gave me some antiinflammatories and sent me on my way.
Doctor: Did you drive yourself?
Patient: Yes, I did.
Doctor: How did the antiinflammatories work?
Patient: Um, by the time I got home, I could hardly walk due to the back pain, and I had weakness in my legs. I was, however, able to feed my dogs, and I fixed myself some dinner.
Doctor: Was there any leg numbness?
Patient: Yes. Since December eleventh.
Doctor: Have you seen an orthopedist for this pain?
Patient: Yes, I saw one the day after my primary care physician, but my legs gave out and I fell while walking to my car because of the leg weakness and back pain.
Doctor: What kind of imaging studies did that orthopedist do?
Patient: He did a C T and x rays of my lower back, but he didn't see anything wrong. He recommended I follow up at U I H C. The imaging was on my L S Spine.

assistant: This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95; began radiating down the RLE, on 12/6/95; then down the LLE, on 12/9/95. By 12/10/95, he found it difficult to walk. On 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. He was given some NSAID and drove home. By the time he got home he had great difficulty walking due to LBP and weakness in BLE, but managed to feed his pets and himself. On 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain. He also had had BLE numbness since 12/11/95. He was evaluated locally and an L-S-Spine CT scan and L-S Spine X-rays were "negative." He was then referred to UIHC.
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: Alright. So this is going to be a complex case. Your wound is complicated by methicillin-resistant staphylococcus aureus cellulitis.
Patient: Is there a treatment for my right leg?
Doctor: There is. It will be more aggressive, but we can do it.

assistant: Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Good morning, young man. You're a patient of Doctor X Y Z, correct?
Patient: Yes sir, that's right. I've seen him for years.
Doctor: I just need to confirm some demographic information before we get started today. So, you're a twenty nine year old white male, correct?
Patient: Yes, doctor. That's all right.
Doctor: Great, thank you. So, what seems to be the problem today?
Patient: Well, I got stung by a Yellow Jacket Wasp yesterday.
Doctor: Do you have a lot of swelling?
Patient: Yes, it's in my right hand and right arm.
Doctor: Have you every been stung by wasps before?
Patient: Yeah, this wouldn't be the first time.
Doctor: Have you had similar reactions before?
Patient: Yeah, I have. I have had one severe reaction. I came because I wanted to make sure it didn't get to that point again. I've never had, um, anaphylaxis, nothing super serious to date.
Doctor: Okay, that's good. Do you have any shortness of breath or difficulty with your throat?
Patient: No, it's never felt like it was going to close up or anything like that.
Doctor: Do you have any rapid heartbeat or anxiety?
Patient: No, I don't have anything like that either.
Doctor: So, it's just the localized swelling where you got stung?
Patient: Yes, that's really all, doctor.

assistant: He is a 29-year-old white male who is a patient of Dr. XYZ and he comes in today complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm. He says that he has been stung by wasps before and had similar reactions. He just said that he wanted to catch it early before he has too bad of a severe reaction like he has had in the past. He has had a lot of swelling, but no anaphylaxis-type reactions in the past; no shortness of breath or difficultly with his throat feeling like it is going to close up or anything like that in the past; no racing heart beat or anxiety feeling, just a lot of localized swelling where the sting occurs.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GYNHX

Dialogue:
Doctor: When was your last menstrual period?
Patient: Um, it was around June third of two thousand nine.
Doctor: Okay so it says you have had an abortion recently?
Patient: Yes I have, but I am not sure if it is finished, because I am still bleeding.
Doctor: Okay.
Patient: Do you want me to do a pregnancy test?
Doctor: No I would have you see our Gynecology and Obstetrician.
Patient: Okay.

assistant: Her last menstrual period was 6/3/2009. The patient is admitting to having a recent abortion done. She is not too sure whether the abortion was completed or not, has not had a followup with her OB/GYN.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ROS

Dialogue:
Guest_family: My nipples are cracked, and they are bleeding.
Doctor: Oh, I am so sorry to hear that.
Guest_family: He has some fluid coming out of his belly button as well as his penis.
Doctor: Okay I will look at it. But other than that, everything else looks good? Any other problems related to circumcision?
Guest_family: No, no other issues.

assistant: Mom's nipples are currently cracked and bleeding. Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area. He is status post a circumcision. Otherwise, review of systems is negative.
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: They gave you Procrit for your anemia?
Patient: Yes I think so. That is how they treated it in the past.
Doctor: Okay. Are you married? Who do you live with?
Patient: Oh I am by myself.
Doctor: Okay, and do you smoke or drink alcohol?
Patient: No I do not.
Doctor: Great.
Patient: Okay.

assistant: As above plus history of anemia treated with Procrit. No smoking or alcohol use and lives alone.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Hello. How are you doing?
Patient: Not doing that good. I'm here so that you can help me.
Doctor: Tell me how can I do that? What's bothering you?
Patient: I have gestational diabetes and I'm here for consultation related to my diet. No matter what I eat, I'm kind of scared that it will spike up my numbers.
Doctor: Hold on, hold on. First, tell me how old are you?
Patient: Sorry. I am thirty eight.
Doctor: Okay, now tell me what are you afraid of?
Patient: No matter what I eat, my number goes up and I just, I'm so afraid of eating anything now.
Doctor: Do you work?
Patient: I do, at Walmart. I try not to eat anything whenever I'm on the third shift.
Doctor: Tell me about the eating habits. Do you prepare meals at home, or do you order from outside?
Patient: Well, before all this, I mean this gestational diabetes and pregnancy, I used to eat out a lot. Almost like every day. I like to eat rice a lot. It is like the staple food for me.
Doctor: You said you don't try to eat, so are you facing any symptoms because of not eating?
Patient: Yeah, whenever I'm on my late shift, I work from ten in the night to seven in the morning. I try to avoid eating. And then I feel very fatigued and tired all the time. I also have young kids at home, so after finishing my duty here at in the morning I go home and then there are young children who keep me busy.
Doctor: What is your sleeping pattern? How much are you sleeping throughout the day?
Patient: Around two to four hours at a time.
Doctor: When do you test for ketones?
Patient: Normally, it is the first thing that I do when I reach back home from my shift in the morning.

assistant: This is a 38-year-old female who comes for dietary consultation for gestational diabetes. Patient reports that she is scared to eat because of its impact on her blood sugars. She is actually trying not to eat while she is working third shift at Wal-Mart. Historically however, she likes to eat out with a high frequency. She enjoys eating rice as part of her meals. She is complaining of feeling fatigued and tired all the time because she works from 10 p.m. to 7 a.m. at Wal-Mart and has young children at home. She sleeps two to four hours at a time throughout the day. She has been testing for ketones first thing in the morning when she gets home from work.
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 old are you? What brings you here today?
Patient: I am fifty six years old. I am here for this pain in my legs. It hurts mostly in the night.
Doctor: Does changing positions helps you?
Patient: Yeah, it helps. Whenever I stand it just goes away.
Doctor: Is it only in your legs or it starts there and goes somewhere else as well?
Patient: It normally starts in my hips and then it goes down my leg and sometimes into my ankles as well.
Doctor: When did you first notice it?
Patient: It all started after taking that medication. What is it called? Something with L? Yeah, Lipitor.
Doctor: Have you ever noticed any night sweats?
Patient: Sometimes I do sweat at night.
Doctor: Any other issue? Anything else going on? Your body temperature is a little on the higher end.
Patient: Yeah, I do feel feverish and have nausea as well.
Doctor: How are your sugar numbers?
Patient: They have been low for quite some time. You know, I have started going to Genesis in Wichita and I've been doing water aerobics. And you know what? Surprisingly, I have lost thirty pounds.
Doctor: That's good. How much is your fasting sugar?
Patient: Anywhere between a hundred to one hundred and twenty. I check them one and a half hours after meals as well. They are, they have been one hundred and eighty five regularly.
Doctor: Okay.
Patient: Yeah. I have a request to make. I will be coming for my diabetic checkup in one month. Can we do all the labs before that?
Doctor: Yeah, sure, that's a great idea. I should tell my assistant and they will call you for labs before your appointment for diabetes checkup.
Doctor: Anything else going on? How is everything else?
Patient: I tried to control my cholesterol with diet, but it didn't help. I cannot keep on dieting. It is just not my thing. I have started eating more meat though. I feel full after that.

assistant: This is a 56-year-old female who has pain in her legs at nighttime and when she gets up it comes and goes, radiates from her buttocks to her legs, sometimes it is her ankle. She has noticed it since she has been on Lipitor. She has had some night sweats occasionally. She has had a little bit of fever and nausea. She has noticed her blood sugars have been low. She has lost over 30 pounds after exercising doing water aerobics at Genesis in Wichita. She has noticed her fasting blood sugars have been ranging from 100 to 120. Blood sugars one and a half hours after meals have been 185. She is coming in for a diabetic checkup in one month and wants lab prior to that time. She has been eating more meat recently and has not been on a diet for cholesterol.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are you married?
Patient: Yes.
Doctor: Do you have kids?
Patient: Yes, I do have seven. I have a handful.
Doctor: Do you work?
Patient: Yeah, I'm a driver for FedEx.
Doctor: Did you ever smoke?
Patient: Nope.
Doctor: What about alcohol or any other kind of drugs?
Patient: Nope. None of that.

assistant: Married, 7 children, driver for Fed Ex. 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: ALLERGY

Dialogue:
Doctor: Is patient allergic to any medication?
Guest_clinician: Yes, actually he is allergic to quite a few medicines. I have noted them down, here is the list.
Doctor: Okay, so he is allergic to Lamisil, Equagesic. Oh, he is allergic to Bactrim too.
Guest_clinician: Yeah, and Dilatrate and cyclobenzaprine.
Doctor: That's quite a lot, we need to be careful while making his treatment plan.
Guest_clinician: Yeah.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Hi there! I am Doctor Smith.
Patient: Hello! It is nice to meet you.
Doctor: Let's start with your family medical history.
Patient: My mother had breast cancer. My father had lung cancer that ended up taking his life. He was seventy nine when he passed. My mother also passed but not from an illness but from an infection she got after having an elective surgery.
Doctor: I am so sorry for your loss. How old was your mother when she passed?
Patient: Thank you. She was eighty one when she passed. I am an orphan now. My only living sibling died at forty. He had a hard life. He struggled with mental illness.
Doctor: How did your brother pass away?
Patient: He had pancreatitis. Oh, my dad had glaucoma.
Doctor: You have had a lot of loss.
Patient: Yes, I have. My good friend passed away a year and a half ago. It has been a lot.
Doctor: I have a support group I can refer you to for people to have been through loss. Would you be interested a referral, sir?
Patient: Yes. I would like that. Thank you.

assistant: Father died from CA at the age of 79. Mother died from postoperative infection at the age of 81. Brother died from pancreatitis at the age of 40 and had a prior history of mental illness. Father also had a prior history of lung cancer. Mother had a history of breast cancer. Father also had glaucoma. He does not have any living siblings. Friend died a year and half 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: PASTSURGICAL

Dialogue:
Doctor: Have you ever had surgery, ma'am?
Patient: Yeah, I've had a few. First, I had, um, tubal ligation, and three milk ducts removed.
Doctor: What year was that in?
Patient: That was in, um, nineteen seventy nine.
Doctor: Great, thank you. What else have you had done?
Patient: I had a breast biopsy in nineteen eighty nine, and a colonoscopy in two thousand seven.
Doctor: Thank you, do you have any children?
Patient: Well, doctor, I've been pregnant four times, but I've had three children.
Doctor: I'm so sorry to hear that. Did you have a C section with any of them?
Patient: No, doctor. I had a natural birth for all of them.

assistant: In 1979, tubal ligation and three milk ducts removed. In 1989 she had a breast biopsy and in 2007 a colonoscopy. She is G4, P3, with no cesarean section.
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: Hi there, how are you dear?
Patient: I am fine, thank you.
Guest_family: Hi Doctor, I am her mother.
Doctor: Nice to meet you. So I see you have been referred by Doctor X.
Guest_family: Yes, she is our family doctor.
Doctor: Okay, so you noticed some behavioral problems with your daughter and reported to her, is that right?
Guest_family: Yes, I have been noticing them for a while. She loses her focus quickly. We also got a few complaints from school regarding her behavior. We also met a couple of other doctors but they diagnosed her with Attention Deficit Hyperactivity Disorder.
Doctor: Well, looking at her reports I am afraid it looks like she does have A D H D, but the good news is we can treat her, so don't worry.
Guest_family: Okay.
Doctor: I am going to prescribe her some medicines which will help her deal with this.
Guest_family: Thank you.
Doctor: So, I will write her a prescription for Adderall and Clonidine. They have some really good results in treating A D H D. Which pharmacy do you go to?
Guest_family: We go to Costco pharmacy by the X Y Z corner.
Doctor: Okay, I will send it there.
Patient: Thank you doctor, it was nice meeting you.
Doctor: Nice meeting you too, take care.

assistant: Adderall and clonidine for attention deficit hyperactivity disorder.
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: He had circumcision?
Patient: Yes.
Doctor: Do you remember the date?
Patient: No I do not. But it should be in the chart.

assistant: Circumcision.