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

user: Section: FAM/SOCHX

Dialogue:
Doctor: What is your family medical history?
Patient: My uncle on my dad's side of the family had kidney failure. I lot of my family members have diabetes and asthma.

assistant: Family history is positive for asthma and diabetes. There is also positive family history of renal disease on the father's side of the family.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: What is your family medical history?
Patient: My dad passed away from a heart attack. He was fifty nine. My mom died from complications with her diabetes.
Doctor: Do you have any siblings?
Patient: Yes. My brother had a bypass with a graft in August of ninety five.

assistant: Father died age 59 of valvular heart disease. Mother died of DM. Brother had CABG 8/95.
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?
Patient: What?
Doctor: How are you related to the patient?
Guest_family: Hello doctor, I am his son.
Doctor: Hello. How old is he?
Guest_family: He is eighty years old. He is suffering from dementia.
Doctor: I see. Do you think he will be able to provide me with his medical history?
Guest_family: I don't think so. Sometimes he even forgets his name.
Patient: He's kidding. I know my name. I also know his kids' names. I do agree that sometimes I forget my things or feel lost.
Doctor: I don't blame you. I forget my things at my age.
Guest_family: Yeah, it is something like episodic that he forgets everything and sometimes he's absolutely normal. On good days, he's very nice to talk to.
Doctor: What is his living status?
Guest_family: He lives at a board and care. It is a cozier homelike place.
Doctor: That's good. So what brings you here in the emergency today?
Guest_family: He started complaining of stomach aches. Luckily, I was there. It was very sudden at one moment he was talking to me nicely and then all of a sudden he started complaining of severe pain in his stomach area. That's when I decided to bring him here in the emergency room.
Doctor: Do you have any previous reports?
Patient: I have these reports.
Doctor: Do you remember when was this scan done?
Patient: I have no idea. I just had these reports with me.
Doctor: Do you remember of any medical issues before?
Patient: Huh uh.
Doctor: Okay, let me see what your scan says. I am reading the C T Scan report provided by the patient. It states that patient has dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.
Patient: Hm.
Doctor: I see that you have already been given some I V fluid along with antibiotics by the emergency room doctor.
Guest_family: Yeah.
Doctor: Did he ever complain of pain during urination or nausea and vomiting?
Guest_family: Yes, he had fever a few days back. When we asked him about other symptoms, he said, it's hard to urinate and it is painful. Nausea and vomiting are something that I am not sure about. He was normally rushing to the restroom and every time used to say he didn't want to pee as it hurt him. He also had a few accidents in the last few days where he wet himself.
Doctor: Thank you for providing me with all his history. It will be very helpful for me to treat him now.

assistant: The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain. In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter. The patient is unable to provide further history. The patient's son is at the bedside and confirmed his history. The patient was given IV antibiotics in the emergency room. He was also given some hydration.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: What is your family medical history?
Patient: My mother had cancer. She had multiple myeloma. She passed away at age eighty three. My dad died when he was eighty one.

assistant: Father passed away at 81; mother of multiple myeloma at 83.
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 are your parents doing?
Patient: Unfortunately, they both passed away.
Doctor: Oh no, I'm so sorry to hear that.
Patient: Thank you, its okay, I manage.

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

user: Section: CC

Dialogue:
Doctor: What's going on?
Patient: I am having a bellyache.
Doctor: Since when?
Patient: Oh, it's been a while now.
Doctor: Okay.
Patient: Yeah.

assistant: Chronic abdominal 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: CC

Dialogue:
Doctor: Hey, what's going on with you today?
Patient: Oh, I have a chest pain.
Doctor: You have fever too?
Patient: Yes, I did.

assistant: Chest pain and fever.
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, how are you?
Patient: I am feeling not so good.
Doctor: What happened and how long since it started?
Patient: Oh, I don't remember it. Just my head is hurting so much.
Guest_family: Hi doctor, she is my mother. Her dementia has progressed and most of the time she does not remember anything.
Doctor: Oh, I see. Let me try and see if she can answer few questions
Guest_family: Sure.
Doctor: Did you have any nausea or vomiting?
Patient: I don't know.

assistant: She has moderate-to-severe dementia and is unable to give any information about history or review of systems.
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: Do you have allergies to any medications?
Patient: Um I'm allergic to Clonidine and Medifast.
Doctor: What happens when you take Clonidine?
Patient: I get a really bad rash.
Doctor: And how about with Medifast?
Patient: I get very tired after taking it. The last time I took it, I had trouble getting out of bed.

assistant: He has known history of allergy to clonidine, Medifast does fatigue.
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 nurses tell me that you're thirty nine years old, is that correct?
Patient: Good morning, Doctor. Yes, that's correct.
Doctor: So, what seems to be the problem today, ma'am?
Patient: I hurt my knee while on the trampoline back in late August.
Doctor: Do you remember the mechanism of injury to this knee?
Patient: What do you mean?
Doctor: Well, was it a twisting, pulling, snapping kind of injury?
Patient: Oh, I twisted my knee.
Doctor: Okay, have you seen another doctor for this?
Patient: Yeah, and I got an M R I.
Doctor: Can I see the report?
Patient: Yes, here you go.
Doctor: This M R I shows an A C L tear. Do you have any instability in this knee?
Patient: Yeah, I feel like my knee joint has been unstable for years.
Doctor: Have there been any dislocations?
Patient: Yeah, there have been. What can be done about this?
Doctor: Well, there's surgery to fix this. I can repair that A C L.
Patient: What are the risks of infection with the procedure?
Doctor: Historically, it's less than one percent. We use antibiotics to control for infection.
Patient: Will I go under for this?
Doctor: Yes, you won't feel a thing.
Patient: Okay, yes, I'd like the surgery done.

assistant: This is a 39-year-old female who has sustained a twisting injury to her knee while on trampoline in late August. She was diagnosed per MRI. An MRI confirmed the clinical diagnosis of anterior cruciate ligament tear. She states she has had multiple episodes of instability to the patellofemoral joint throughout the years with multiple dislocations. She elected to proceed with surgery to repair the anterior cruciate ligament as well as possibly plicate the medial retinaculum to help prevent further dislocations of the patellofemoral joint. All risks and benefits of surgery were discussed with her at length. She was in agreement with the treatment plan.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Can you tell me more about your family history, ma'am? How is your father doing?
Patient: Well, doctor, my father passed away from leukemia a while back.
Doctor: I'm so sorry to hear that. What about your mother? How is she doing?
Patient: She died too. She had kidney and heart failure.
Doctor: I'm sorry, ma'am.
Patient: Oh, it's okay doctor, thank you.
Doctor: Do you have any siblings?
Patient: Yes, I have two brothers and five sisters.
Doctor: That's a big family, do they have any conditions that you know about?
Patient: One of my sisters has breast cancer.
Doctor: Okay, thank you. Do you have any children?
Patient: Yeah, I have two sons and a daughter.
Doctor: That's great. Do you have any other conditions I should know about?
Patient: Well, in addition to all of that, there's some high cholesterol, um, depression, and a nervous condition.

assistant: Her father died from leukemia. Her mother died from kidney and heart failure. She has two brothers; five sisters, one with breast cancer; two sons; and a daughter. She describes cancer, hypertension, nervous condition, kidney disease, high cholesterol, and depression in her family.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: CC

Dialogue:
Doctor: Hi there! What brings you in today?
Patient: I have not been feeling well. I am tired and feel weak.
Doctor: Have you had any other symptoms?
Patient: I noticed after I went to the bathroom this morning, that my urine was dark.
Doctor: Have you been staying hydrated?
Patient: Yes.
Doctor: Lets get a urine sample. I will have the nurse come in with a sample cup.
Patient: Okay.

assistant: Dark urine and generalized 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: OTHER_HISTORY

Dialogue:
Doctor: Hello, how are you?
Patient: I am doing well. Just here for a follow up visit.
Doctor: Are there any changes from the last visit in your social history or medical history?
Patient: No. Whatever you wrote last time should be correct. I was here just three months ago. I was here December third of two thousand and three.

assistant: Reviewed and unchanged from the dictation on 12/03/2003.
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: Welcome to the clinic.
Patient: Thank you.
Doctor: I would like to start with your medical history. Do you have any medical problems or conditions?
Patient: I don't have any medical conditions other then the one I was sent to you for.
Doctor: Yes. Doctor Hanine sent over your recent blood test results and chart notes. Did he discuss those results with you?
Patient: Yes, he did. He said I have multiple myeloma. And that the blood work levels are how he found it.
Doctor: Yes. The I G G levels show that the subtype is multiple myeloma.
Patient: Okay.

assistant: History of IgG subtype multiple myeloma.
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: So, how are feeling?
Doctor: You came here last time with C V A right?
Patient: Yeah, I am recovering well. You asked me to follow-up for high sugar.
Doctor: Oh yeah, you have diabetes mellitus. Did you happen to get a blood test done before this visit?
Patient: Yes, I did here is the report.

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

user: Section: CC

Dialogue:
Doctor: What brings you here today?
Patient: I have a queasy tummy and the feeling that I am about to throw up all the time.
Doctor: Anything else?
Patient: I'm actually throwing up a lot.

assistant: Vomiting and nausea.
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: Yeah, here and there.
Doctor: On average, how many cigarettes would you say you smoke?
Patient: Probably three or four if I had to guess.
Doctor: Any medical problems that run in the family?
Patient: Yeah, my brother had a heart attack when he was pretty young.
Doctor: How old was he?
Patient: Fifty two.
Doctor: Oh wow, how's he doing?
Patient: Good, he has to see a heart doctor at least once a year.
Doctor: Does anyone else in your family have heart problems?
Patient: Um my dad has some heart issues. He's also a type one diabetic.

assistant: Her father has type I diabetes and heart disease. She has a brother who had heart attack at the age of 52. He is 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: FAM/SOCHX

Dialogue:
Doctor: Hello, miss. How are you doing?
Patient: I am fine. I just have a few questions about diet and exercise. I want to get my health in order.
Doctor: Okay, great. That's something we can handle today. Can you tell me about your familial history? This will help me see any possible ailments that we should watch out for.
Patient: Yes. So let's start with my mom. She died of congestive heart failure.
Doctor: How about your father? Your paperwork says both parents are deceased.
Patient: Yes, unfortunately. My dad died from myocardial infarction at fifty six years old. Not sure how old my mom was.
Doctor: Your family seems to have a history of ischemic cardiac disease. How are your siblings? The paperwork says you have brothers.
Patient: Yes. Two are alive and one has passed. He died from lymphoma. One brother has had two angioplasties and the other brother just has asthma.

assistant: Reviewed. Mother died from congestive heart failure. Father died from myocardial infarction at the age of 56. Family history is positive for ischemic cardiac disease. Brother died from lymphoma. She has one brother living who has had angioplasties x 2. She has one brother with 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: ALLERGY

Dialogue:
Doctor: Are you allergic to anything?
Patient: No, I am not.
Doctor: How about food allergies.
Patient: No, I am fine.
Doctor: Okay.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you smoke?
Patient: Yeah, I smoke weed every now and again. It helps with my anxiety.
Doctor: How about cigarettes?
Patient: No, not the least bit interested in cigs.
Doctor: Good to keep it that way.

assistant: The patient smokes marijuana. The patient does not smoke 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: GENHX

Dialogue:
Doctor: Hello! Who do we have here today?
Guest_family: Hello, this is our son, A B C.
Doctor: How old is he? What is the issue?
Guest_family: He is two. He is continuously complaining of pain in his belly and back. He is active otherwise.
Doctor: Did you notice any change in his toilet habits or routine?
Guest_family: No.
Doctor: Any fever or chills or any other issue?
Guest_family: No, we did not notice any such issues, he has been active and was acting very normal otherwise.
Doctor: Any change in his eating habits?
Guest_family: No, he has been eating and drinking as usual. He was acting normally but we did notice a foul odor coming from his nose. He was on antibiotics after removal of that piece of cotton from his right side of nose in our previous visit here.
Doctor: How is his nose now?
Guest_family: He got better but now we can notice that odor from his nose again.
Guest_family: His mother started him on the antibiotics again, whatever was remaining, we think something is still there.
Doctor: Okay, Is there anything else like runny nose or any pain in his ear or bad throat? How about cough or congestion? Or any other issues you have noticed?
Guest_family: No, nothing of those instead he has been active and eating and drinking normally, no other issue.
Doctor: Is he complaining of any pain or discomfort on bowel movements? Is there any increase in the frequency of urination?
Guest_family: Well, we can't say it for sure as he still wears diapers but we have not noticed anything abnormal.

assistant: Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels. They have not noted him to have any fevers or chills or any other illness. They state he is otherwise acting normally. He is eating and drinking well. He has not had any other acute complaints, although they have noted a foul odor coming from his nose. Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics. His nose got better and then started to become malodorous again. Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there. Otherwise, he has not had any runny nose, earache, no sore throat. He has not had any cough, congestion. He has been acting normally. Eating and drinking okay. No other significant complaints. He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper.
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 tell me about the medications that you are currently using?
Patient: I am taking Alesse twenty eight.
Doctor: Do you know its strength? Um, like how many milligrams?
Patient: Oh yes, it is twenty M C G and I take point ten milligrams of it.
Doctor: When did you start it?
Patient: On seventh August in two thousand and one.
Doctor: Who prescribed it?
Patient: My O B G Y N, Doctor A.

assistant: Patient is currently taking Alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001 medication was prescribed by Obstetrician-Gynecologist A.
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 type of surgeries have you had in the past?
Patient: I don't know what surgery they did today. I mean I don't know the name of it.
Doctor: It's okay, I know. It is Lap Band.
Patient: And I have had right side foot surgery done in the past.
Doctor: Okay great.
Patient: Sure.

assistant: 1. Lap-Band done today. 2. Right foot surgery.
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:
Patient: Oh doc, I've had a lot of trouble breathing lately.
Doctor: I'm sorry to hear that. We'll get to the bottom of it.
Patient: Yeah, I lose my breath so quickly with just one to two flights of stairs.
Doctor: When did you first start noticing this?
Patient: I believe two weeks ago.
Doctor: Any chest pain or tightness with the shortness of breath?
Patient: No, thankfully.
Doctor: Any fever, chills, or sweats?
Patient: No.
Doctor: Any cough or coughing up blood?
Patient: No.
Doctor: How about wheezing or swelling in your legs?
Patient: No.

assistant: Dyspnea on exertion. No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Can you tell me more about your family medical history, sir? How's your dad doing?
Patient: Well, doctor, he passed away. He had mesothelioma.
Doctor: I'm so sorry to hear that, sir. How is your mother?
Patient: It's okay, thank you. I lost her too. She had A L S.
Doctor: I'm sorry, that must be so hard.
Patient: Yes, it is, but I manage.

assistant: His father died of mesothelioma and his mother died of Lou Gehrig's 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: So, tell me did anyone in your family have Idiopathic pulmonary fibrosis?
Patient: Actually, my father passed away due to this disease.
Doctor: Oh, sorry to hear that.
Patient: Yeah.
Doctor: Anything else that he or any other family member might have.
Patient: Oh, he also had this spastic colon problem and irritable bowel syndrome.
Doctor: Hm, I see.
Doctor: Anything else?
Patient: No.

assistant: Significant for his father who died of IPF and irritable bowel syndrome.
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: How are you today?
Patient: I am doing okay.
Doctor: Do you have any medical conditions?
Patient: I have diabetes.
Doctor: When were you diagnosed with diabetes?
Patient: It was two thousand and three, I think. I also have high blood pressure, asthma and high cholesterol.
Doctor: Okay.

assistant: He has had diabetes since 2003. He also has asthma, hypertension, and hypercholesterolemia.
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: I do not feel any swellings in your neck or groin area.
Patient: Oh yeah, I don't notice anything either.
Doctor: Okay yeah, I was just trying to look for any lymph nodes.
Patient: Okay.
Doctor: Let me check.
Patient: Sure.

assistant: LYMPH: There was no appreciated node that I could feel in the groin or neck area.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ASSESSMENT

Dialogue:
Doctor: Your bloodwork came back from the Coumadin sensitivity test. The results showed a high level of sensitivity. I am going to adjust your dosage of Coumadin to a much lower dose. This will help reduce the bruising and the bleeding episodes. Do you have any questions?
Patient: No.

assistant: Hypersensitivity to Coumadin.
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. You must be his mom.
Guest_family: Yeah, he started having a sore throat last night. And that's why we are here. His eyes have been really puffy. Uh, we gave him some Benadryl.
Doctor: Hm.
Patient: I had a stuffy nose and it was hard to breathe.
Doctor: When did it all start?
Guest_family: It started yesterday. All of a sudden, he started complaining saying, “Mama my nose is not working,” and yeah, I noticed he was breathing from his mouth.
Doctor: Any fever or any other symptoms?
Guest_family: Yeah, he had some low grade fever. He looked very tired and when I asked him he said that, “I feel like I cannot stand. I have no energy. I want to just lie down.”
Doctor: I can notice that his voice is a little bit hoarse. How's he eating and drinking?
Guest_family: He's eating and drinking normally.
Doctor: Any shortness of breath or pain in your stomach?
Patient: No.
Doctor: Any diarrhea or vomiting?
Patient: No.

assistant: Mom brings patient in today because of sore throat starting last night. Eyes have been very puffy. He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday. He has had low-grade fever and just felt very run down, appearing very tired. He is still eating and drinking well, and his voice has been hoarse but no coughing. No shortness of breath, vomiting, diarrhea or abdominal 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: GENHX

Dialogue:
Doctor: What's a young thirty one year old like you doing in my office today, ma'am?
Patient: Well, I got referred to P T after I had a fall.
Doctor: When was your fall?
Patient: Um, it was on October third two thousand eight.
Doctor: What happened when you fell?
Patient: I tripped over my dog's toy.
Doctor: Did you twist your foot or ankle?
Patient: Yeah, my left foot inverted.
Doctor: Have you had any imaging done on this foot?
Patient: Yeah, um, I've had x rays and an M R I already.
Doctor: What were the impressions of those images?
Patient: They told me that it was unremarkable.
Doctor: How was the pain progressed since the onset?
Patient: Well, after a month or so, the pain is still so bad I can't do any of my activities.
Doctor: How long have you been wearing this walking boot?
Patient: Um, it's been about a month now.

assistant: The patient is a 31-year-old female who was referred to Physical Therapy secondary to a fall on 10/03/08. The patient states that she tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.
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: No, that never really appealed to me, doctor.
Doctor: Good, what about more illicit substances?
Patient: Oh, most certainly not.
Doctor: What about alcohol, do you drink?
Patient: Well, I'd say I'm an occasional drinker.

assistant: The patient is a nonsmoker and does not use illegal drugs. Occasionally drinks.
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 mind elaborating more on your family history? Did either of your parents suffer from any medical problems?
Patient: Sure. My dad had heart disease. He passed at seventy five. He had a sister with diabetes and I think my mom may have had diabetes as well.
Doctor: Got it.
Patient: As for my mom, she had a long history of mini strokes. She didn't have any memory problems or dementia when she passed at eighty five. They believe she passed due to old age.
Doctor: Thank you for further elaborating. I'm so sorry for your losses. Losing a parent let alone two is profoundly difficult.

assistant: Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85. In addition, his father had a history of heart disease and passed away at the age of 75. He has one sister with diabetes and thought his mom might have had diabetes as well.
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: Any muscular pain?
Patient: No, not really.
Doctor: Any problem in walking?
Patient: No, it's normal.
Doctor: Let me check your toes and fingers. Can you move them for me?
Patient: Yeah.
Doctor: Everything looks fine. Nails looks fine too. No bluish discoloration no sign of any infection. Can you push your legs against my hand.
Patient: Both legs?
Doctor: Yes, both. Well, your muscular strength is equal and stable in both legs, so that's fine. Motion looks adequate.
Doctor: Any tenderness?
Patient: No.
Doctor: And I don't see any swelling or fluid accumulation.
Patient: Okay.

assistant: MSK: Normal gait and station. No pathology to digits or nails. Extremities move times four. No tenderness or effusion. Range of motion adequate. Strength and tone equal bilaterally, stable.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ROS

Dialogue:
Doctor: Have you experienced any headaches or blackouts recently?
Patient: No.
Doctor: Dizziness or seizure?
Patient: Nope.
Doctor: Any history of stroke?
Patient: No.
Doctor: Okay, good.

assistant: NEUROLOGIC: Normal; Negative for blackouts, headaches, seizures, stroke, or dizziness.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Hi there! I am Doctor Kim. Nice to meet you, miss.
Patient: Hi! Nice to meet you.
Doctor: How are you feeling today?
Patient: I am feeling much better today.
Doctor: How old are you?
Patient: I am forty six.
Doctor: How is your pain in the left side?
Patient: It is much better. It is more like a dull pain now.
Doctor: Are you still having trouble with urination?
Patient: It has gotten better but is still a little difficult.
Doctor: Okay. It looks like Doctor X did an exam yesterday. Doctor X consulted me on your status but I have a question for you. I see in your medical history that you had a bruised left kidney. Can you tell me more about the bruised kidney?
Patient: Yes. I was in a car accident, years ago. The doctor told me that I had a bruised left kidney. They thought it was due to the accident, but they could not be certain.

assistant: The patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating. Details are in the history and physical. She does have a vague history of a bruised left kidney in a motor vehicle accident. She feels much better today. I was consulted by Dr. X.
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: Well, I have a long family history of heart problems. My mom died quite young at the age of fifty due to heart attack and my father was detected with heart failure, he has a pacemaker.
Doctor: Oh, I am sorry to hear about your mom.
Patient: Yeah. Also, high blood pressure runs in my family.
Doctor: Okay.

assistant: She described a family history of hypertension. Her mother died after a myocardial infarction at age 59. Her father was diagnosed with congestive heart failure and had a pacemaker placed.
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: Where are you experiencing the most pain?
Patient: All over my belly.
Doctor: How long has this been going on?
Patient: Two to three weeks.
Doctor: Does the pain come and go?
Patient: It does.
Doctor: And how would you describe-
Patient: The pain?
Doctor: Yes.
Patient: Hm I'd describe it as a gnawing sensation.
Doctor: Is this sensation new?
Patient: I believe so. I don't ever remember feeling this way before.
Doctor: Any past abdominal surgeries?
Patient: None.

assistant: Abdominal 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: Hi, there.
Patient: Hi.
Guest_family: Hi! It is nice to meet you.
Doctor: It is nice to meet you as well. You are the husband, correct?
Guest_family: Yes. I am the husband.
Doctor: How long have you two been married?
Guest_family: We have been married for forty eight years.
Doctor: Do you live in the same household?
Patient: Yes.
Doctor: Do you have a primary care physician?
Patient: No, I am currently looking for someone. I have also been looking for someone to see for my mental health issues.
Doctor: I have a few recommendations I can give to you if you would like.
Patient: I would like your recommendations for both.
Doctor: Are you working currently?
Patient: No, I am not. I used to work as a registered nurse. It has become too much for me right now.
Doctor: Do you drink alcohol or use any recreational drugs?
Patient: I don't do any drugs. I drink very rarely. I only drink is social situations.
Doctor: Have you ever taken any prescription drugs, muscle relaxants or sedative medications?
Guest_family: I don't think that she has ever taken muscle relaxants or sedative medications without prescriptions. I give her, her medications every day so she doesn't forget.
Doctor: Oh, okay.
Guest_family: She does have a pattern of self-prescribing for minor illness. She loves WebMD.
Doctor: Okay. How have you been feeling lately? Have you been participating in social activities?
Patient: Since this last March I have been feeling more social and have been doing things on my own more.
Guest_family: She used to never leave the house unless I go with her. She has defiantly been more independent lately. She even went and met a friend for coffee the other day.
Doctor: That is great to hear.

assistant: The patient lives with her husband of 48 years. She used to be employed as a registered nurse. Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions. She rarely drinks socially. She denies any illicit substance usage. Her husband reportedly gives her medication daily. Has been proactive in terms of seeking mental health care and medical care. The patient and husband report that from March 2009, she has been relatively independent, more socially active.
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: Do you have a history of surgeries?
Patient: I had a bone fragment removed from my right arm. I had a D and C done a long time ago. It was a treatment for H P V. More recently I had an ovarian cancer staging biopsy done. I have not heard back with the results yet. I only had it done less then a week ago.
Doctor: How are you feeling after the biopsy?
Patient: I had a significant amount of pain for two to three days after. I feel better now.

assistant: 1. A D and C. 2. Bone fragment removed from her right arm. 3. Ovarian cancer staging.
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 Jane, how are you?
Patient: I am good, thank you for asking.
Doctor: So, tell me what brings you here?
Patient: I have so many issues and problems, where do I start?
Doctor: Start by telling the one troubling you the most.
Patient: I have this pain in my toes on the right side and I also feel this numbness there.
Doctor: Okay and do you feel any tingling sensation? Or feeling like your leg is giving away?
Patient: Yes, I feel the tingling and sometimes. I feel like my leg has fallen asleep.
Doctor: Hm, tell me about your pain. Is it mild, moderate, or severe?
Patient: Well, I will say it's moderate.
Doctor: Would you define it as sharp shooting pain or dull kind of radiating pain?
Patient: Maybe sharp pain but I am not sure how to describe it. But it radiates up the leg.
Doctor: Okay. How long have you had this problem?
Patient: It's been there for almost one year but now it started to get worst.
Doctor: I see, does it get worse when you walk?
Patient: No, mostly when I am in bed. And sometimes I feel it on my left toe as well.
Doctor: It looks like you have paresthesia in the toes of your right foot and I feel your left toe also has the same problem.
Patient: Yeah, I thought so. I read over the internet. But anyways, I am also having this shoulder pain on both sides, plus I am not able to sleep at night.
Patient: I have high blood pressure and hypothyroidism.
Doctor: Well-
Patient: Well, that's not it. I have thrombo-
Doctor: Thrombocythemia.
Patient: Yeah, that.
Doctor: How are your allergies by the way?
Patient: I have no sinus allergies, thankfully.

assistant: The patient is in with several medical problems. She complains of numbness, tingling, and a pain in the toes primarily of her right foot described as a moderate pain. She initially describes it as a sharp quality pain, but is unable to characterize it more fully. She has had it for about a year, but seems to be worsening. She has little bit of paraesthesias in the left toe as well and seem to involve all the toes of the right foot. They are not worse with walking. It seems to be worse when she is in bed. There is some radiation of the pain up her leg. She also continues to have bilateral shoulder pains without sinus allergies. She has hypothyroidism. She has thrombocythemia, insomnia, and hypertension.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Guest_family: He is coughing for one week now.
Doctor: How about any congestion? Is it one week or more?
Guest_family: No did I say that? I meant two to three weeks. I am so worried. He is just one year.
Doctor: Don't worry let me see, can you tell me everything from the beginning?
Guest_family: Sure. It started off as a congestion, but then he started coughing about a week ago and it is getting worse.
Doctor: Okay, what else?
Guest_family: Actually, he had Pop Can just three days ago and I never found the top of that and was wondering if he had swallowed that.
Doctor: It is possible, have you seen any change in his breathing?
Guest_family: His breathing has not gotten worse since that happened.
Doctor: Any fever?
Guest_family: No. No fever.
Doctor: Okay.

assistant: This is a 1-year-old male who comes in with a cough and congestion for the past two to three weeks. Started off as a congestion but then he started coughing about a week ago. Cough has gotten worsen. Mother was also worried. He had Pop Can just three days ago and she never found the top of that and was wondering if he had swallowed that, but his breathing has not gotten worse since that happened. He is not running any fevers.
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 are you?
Patient: I am good, Doctor.
Doctor: So, I see you recently moved to U S A from Brazil, right?
Patient: Yes, about one year back. I was an engineer manager back there, but my job was so stressful that when I got admitted in the M B A program here in the states, I took it.
Doctor: Wow, that's quite a move!
Patient: Yeah.
Doctor: How about your family; wife or girlfriend?
Patient: I am a one women man. I married my childhood sweetheart.
Doctor: Nice. Did you travel outside the country recently or have risk of any kind of exposure?
Patient: No, I haven't traveled anywhere not even within the country.
Doctor: Okay. Tell me something, do you smoke or drink?
Patient: No, I don't.
Doctor: And have you in the past used any recreational or illegal drugs?
Patient: No, never.
Doctor: Okay, good.

assistant: The patient was from Brazil. He moved to the United States one year ago. He denied any history of tobacco, alcohol, or illicit drug use. He was married and monogamous. He worked as an engineer/manager, and stated that his job was "very stressful". He had recently been admitted to an MBA program. The patient denied recent travel or exposures of any kind.
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, sir?
Patient: No, I don't drink at all.
Doctor: How about tobacco? Do you smoke?
Patient: Well, yes.
Doctor: How much do you smoke, sir?
Patient: I smoke about a half a pack of cigarettes a day.

assistant: He does admit to one half pack of cigarette consumption per day. He denies any alcohol consumption.
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? You have been sick?
Patient: Yes, I am not feeling well for the last three days. I have bad body aches, cough and a sore throat.
Doctor: Do you get wet cough or it's dry? What color sputum comes out?
Patient: It is wet and green colored stuff comes out.
Doctor: Okay we will need to send it out to culture, maybe an infection.
Doctor: How about fever, chills, nausea, vomiting, diarrhea anything like that? Are you sleeping well?
Patient: Everything is fine except some chills? I am sleeping okay.
Doctor: Do you need anything for cough?
Patient: I don't need anything for the cough. I did call yesterday and got a refill of my Keflex. Then I took two Keflex this morning and I am feeling little bit better now.
Doctor: Okay then why are you crying, ma'am?
Patient: I am just tired of feeling like ran down.
Doctor: I am so sorry.
Patient: Hm.

assistant: XYZ is in today not feeling well for the last three days. She is a bit sick with bodyaches. She is coughing. She has a sore throat, especially when she coughs. Her cough is productive of green colored sputum. She has had some chills. No vomiting. No diarrhea. She is sleeping okay. She does not feel like she needs anything for the cough. She did call in yesterday, and got a refill of her Keflex. She took two Keflex this morning and she is feeling a little bit better now. She is tearful, just tired of feeling ran down.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: CC

Dialogue:
Doctor: Hi there, what's going on with you?
Patient: Well, I am having this weird jerky movement in my arm and leg.
Doctor: Oh okay, let me take a look.

assistant: Arm and leg jerking.