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: You recently turned sixty seven, correct?
Patient: Yes. Sixty seven years young.
Doctor: Are you right or left handed?
Patient: Right.
Doctor: When were you first diagnosed with Parkinson's?
Patient: September first of nineteen ninety five.
Doctor: Do you remember who diagnosed you?
Patient: A local doctor I was seeing at the time. A year before my diagnosis, I had a few falls and episodes of lightheadedness. I also noticed that I was staggering a lot more when walking.
Doctor: Did you lose consciousness during any of your falls?
Patient: Not that I know of. I had noticed that I was losing my normal voice to a degree. On top of losing my normal voice, my handwriting became smaller and smaller. I don't ever remember writing so small. Something seemed really off to me.
Doctor: I'm sure that was difficult to experience.
Patient: It was very difficult. Two months prior to being diagnosed, I started to move much slower than before.
Doctor: By slower, do you mean the movements of your arms and legs were slower and impaired?
Patient: Yes. I was prescribed Sinemet back in September of nineteen ninety five.
Doctor: Did you notice any improvement while taking it?
Patient: None. I was pretty disappointed and discouraged as a result. I have problems with coordination and walking without staggering even today.
Doctor: Noting that it's February thirteenth nineteen ninety six.
Patient: I felt weak in the morning and worse as the day went on.
Doctor: Are you experiencing any other symptoms, such as stroke like events, vision changes, seizures, or problems with moving and coordinating your arms?
Patient: No.
Doctor: Any headache, nausea, vomiting, chills, or fever?
Patient: No.

assistant: This 67y/o RHF was diagnosed with Parkinson's Disease in 9/1/95, by a local physician. For one year prior to the diagnosis, the patient experienced staggering gait, falls and episodes of lightheadedness. She also noticed that she was slowly "losing" her voice, and that her handwriting was becoming smaller and smaller. Two months prior to diagnosis, she began experienced bradykinesia, but denied any tremor. She noted no improvement on Sinemet, which was started in 9/95. At the time of presentation, 2/13/96, she continued to have problems with coordination and staggering gait. She felt weak in the morning and worse as the day progressed. She denied any fever, chills, nausea, vomiting, HA, change in vision, seizures or stroke like events, or problems with upper extremity coordination.
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! How are the both of you doing today?
Guest_family: I am doing well but my son is sick. He is two and a half years old.
Doctor: What are his symptoms?
Guest_family: He has a bad cough. He's been sick for the last three or four days. It sounds like there is phlegm rattling around in there when he coughs. He had a bad coughing fit this morning. I got nervous and decided to bring him in.
Doctor: During his coughing episode this morning, did you notice any loss of breath or gasping for air?
Guest_family: No.
Doctor: Has he had a runny nose?
Guest_family: No.
Doctor: Any fever?
Guest_family: No. He has not been eating much.
Doctor: Is anyone else in the household sick?
Guest_family: No.
Doctor: Is anyone in the household a smoker?
Guest_family: No.

assistant: The patient is a two-and-a-half-month-old male who has been sick for the past three to four days. His mother has described congested sounds with cough and decreased appetite. He has had no fever. He has had no rhinorrhea. Nobody else at home is currently ill. He has no cigarette smoke exposure. She brought him to the emergency room this morning after a bad coughing spell. He did not have any apnea during this episode.
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 diseases in the family?
Patient: Yeah, mainly heart issues. My father died from heart attack.
Doctor: What about your mother?
Patient: She had the second type of diabetes.

assistant: Father died of an MI, Mother had DM type II.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you drink or smoke, ma'am?
Patient: No, I don't do any of that.
Doctor: Good, what about harder drugs?
Patient: No, none of that either.
Doctor: Very good. Do you have any history of S T D that you know about?
Patient: No, there's no history of any of that there.

assistant: Patient denies smoking, alcohol abuse, illicit drug use and STDs.
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: What medications are you taking?
Patient: I take Prilosec and Tramadol when I have back pain.

assistant: 1. Prilosec. 2. Tramadol p.r.n.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ASSESSMENT

Dialogue:
Doctor: How often are you vomiting?
Patient: At least three times until my stomach is empty.
Doctor: Can you think of something this is related to?
Patient: Just when I eat raw carrots and celery.
Doctor: Do you get belly pain?
Patient: Yes.

assistant: Report of vomiting and abdominal pain after eating raw carrots and celery. Etiology of this is unknown.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Good morning, ma'am. Can you confirm your age for me?
Patient: Well, doctor, I'm sixty six years old now.
Doctor: Thank you, so, how is your knee doing today? Hope the osteoarthritis is getting better.
Patient: It's so bad, doctor.
Doctor: Have you had any improvement with the rest and antiinflammatories we've talked about before?
Patient: No, they haven't helped at all.
Doctor: I see, you'd be a good candidate for a knee replacement.
Patient: What's the risk of infection from the surgery?
Doctor: Historically, it's less than one percent, we use prophylactic antibiotics to control for infection the entire time.
Patient: Great, and will I be asleep for this?
Doctor: Yes, you won't feel a thing.

assistant: A 66-year-old female with knee osteoarthrosis. Failed conservative management. Risks and benefits of different treatment options were explained. Informed consent was obtained.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: How old are you?
Patient: I am twenty four.
Doctor: What brings you in today?
Patient: I have been having this back pain for a long time. I thought I should come and get it checked out because it has not gotten any better.

assistant: A 24-year-old female with chronic back 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: Any medical issues running in your family?
Patient: I don't know anything about that.
Doctor: You know anyone in your family or relatives who ever had diseases like diabetes or any heart issues?
Patient: Nope.

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

user: Section: GENHX

Dialogue:
Doctor: Hello, miss. Could you verify your age, please?
Patient: I'm fifty five years old.
Doctor: Great. What is the reason for your visit today?
Patient: I've been having a lot of problems recently, so I decided to come get it checked out by you.
Doctor: I see. What kind of problems are you experiencing?
Patient: Oh, it's a long list. Here it is.
Doctor: Thank you. Let me take a look. Looks like you have some general allergies and food allergies, loss of taste, problems with your G I tract, asthma, G E R D, and dry mouth or xerostomia.
Patient: Yeah, that sounds about right. I think I forgot to add it, but I also have bad allergies during the spring time.
Doctor: Oh, I see. I would describe that as environmental inhalant allergies.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are you a smoker?
Patient: Yes.
Doctor: Do you use alcohol or any recreational drugs?
Patient: I have been in treatment for heroin and alcohol in the past.
Doctor: Any current use of drugs or alcohol?
Patient: I did do a little bit of coke today.
Doctor: Okay.

assistant: The patient is a smoker. Admits to heroin use, alcohol abuse as well. Also admits today using cocaine.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: MEDICATIONS

Dialogue:
Doctor: Do you take any-
Patient: Meds?
Doctor: Yes.
Patient: I do. I take Allegra for seasonal allergies. I also take something that starts with a P. I'm blanking on the name. My other doctor prescribed it to me for exercise induced asthma.
Doctor: Oh, do you mean Proventil?
Patient: Yes, that's it! I keep that on hand in case my asthma gets outta control.
Doctor: Is it up to date?
Patient: You mean is it expired? No, I don't think so. It hasn't been long since I visited the pharmacy.
Doctor: Good. I always like to advise my patients to check expiration dates.

assistant: Proventil and Allegra.
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: Welcome into the office.
Patient: Thank you.
Doctor: Let us start with your family medical history.
Patient: That is going to be a hard one. I was adopted and I do not know any family medical history.
Doctor: Okay. That is alright.

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

user: Section: PASTMEDICALHX

Dialogue:
Doctor: So, I see you were diagnosed with an acid reflux problem and high blood pressure twenty years back?
Patient: Yes.
Doctor: And then you also have arthritis and Parkinson's.
Patient: Yes, both.
Doctor: Also, you had a brain stroke?
Patient: Yes, mini stroke!
Doctor: Ah, yes. We also call it as T I A.
Patient: Okay.
Doctor: And currently are you on any medications?
Patient: Just Coumadin, for my chronic A Fib. I have been on it three years.
Doctor: Yeah, atrial fibrillation.
Patient: Yes.

assistant: GERD, hypertension times 20 years, arthritis, Parkinson's, TIA, chronic atrial fibrillation, on Coumadin three 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: GENHX

Dialogue:
Doctor: Good morning, ma'am.
Patient: Good morning, doctor.
Doctor: How are you feeling today?
Patient: Honestly, I'm feeling a little bit better.
Doctor: That's good to hear, ma'am.

assistant: The patient states she is feeling a bit better.
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:
Guest_clinician: I see here that he may need antibiotic therapy for possible cellulitis of his lower extremities.
Doctor: According to the patient, his symptoms started getting progressively worse over the past two days.
Guest_clinician: Does he have a history of cellulitis?
Doctor: No.

assistant: Questionable need for antibiotic therapy for possible lower extremity 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 afternoon, young man.
Patient: Good afternoon, doctor.
Doctor: How old are you, sir?
Patient: I'm thirteen.
Doctor: So, what brings you in today?
Guest_family: Well, at first, we went to Sierra Pacific Orthopedic Group, and he had an M R I that showed, um, O C D in the left knee.
Doctor: Yes, I see that from the report.
Guest_family: So, we're here for a second opinion on that.
Doctor: Yes, we should do surgery on this knee. There's gross instability of the fragment, and we don't want that get worse.
Guest_family: Okay, that's about what we've heard so far. What are the risks of infection of the procedure?
Doctor: It's less than one percent. We use antibiotics to control for infection. Other risks include bleeding, changes in sensation of the limb, changes in motion, failure to relieve pain or restore the articular cartilage, the possible need for another procedure, and possible early arthritis. I would not worry, though. These things are rare.
Guest_family: Okay, will he be asleep the entire time?
Doctor: Yes, he won't feel a thing.
Guest_family: Okay, my husband agrees. We want to do the surgery.

assistant: The patient is 13-year-old male with persistent left knee pain. He was initially seen at Sierra Pacific Orthopedic Group where an MRI demonstrated unstable OCD lesion of the left knee. The patient presented here for a second opinion. Surgery was recommended grossly due to the instability of the fragment. Risks and benefits of surgery were discussed. The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure to relieve pain or restore the articular cartilage, possible need for other surgical procedures, and possible early arthritis. All questions were answered and parents agreed to the above 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: Good afternoon, young lady.
Patient: Good afternoon, doctor.
Doctor: Let's get the personal questions out of the way to begin, shall we?
Patient: Sure.
Doctor: Have you had any S T D s recently?
Patient: No, not that I know of.
Doctor: Are you sexually active?
Patient: No, I'm not.
Doctor: I'm looking here, and your last P P D was negative, but we'll do another one today.
Patient: Okay, that's fine, doctor.
Doctor: Have you been compliant with all of the medicine you've been prescribed?
Patient: Yes, I've taken everything exactly as you told me to.
Doctor: Good, do you remember when your last dentist appointment was?
Patient: Yeah, it was in November of two thousand seven.
Doctor: What did they do for you at your last visit?
Patient: They pulled two teeth for me.
Doctor: Good, and when was your last pap smear?
Patient: It was about a year ago.
Doctor: I assume it was negative?
Patient: Yes, thankfully.
Doctor: Have you had a mammogram yet?
Patient: No, not yet. I'm not old enough.
Doctor: Do you have a family history of breast cancer?
Patient: No, I don't, at least not that I know of.

assistant: She has had no recent STDs and she is not currently sexually active. PPD status was negative in the past. PPD will be placed again today. Treatment adherence counseling was performed by both nursing staff and myself. Again, the patient is a 100% compliant with her meds. Last dental exam was in 11/07, where she had 2 teeth extracted. Last Pap smear was 1 year ago was negative. The patient has not had mammogram yet, as she is not of the age where she would start screening mammogram. She has no family history of breast cancer.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: EXAM

Dialogue:
Doctor: Hi, I would like to physically examine your rectal area, ok?
Patient: No, I am not comfortable with that. I don't want you to do that.

assistant: RECTAL: Examination was deferred.
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, what brings you here today?
Patient: I fell four times on third of this month because my leg suddenly gave out.
Doctor: How old are you?
Patient: You don't ask age of a lady. She will never tell you the truth.
Doctor: I know I'm in the wrong profession. I have to do that every time I meet someone. So how old are you?
Patient: That's true. I'm just teasing you. I'm fifty one.
Doctor: Are you right handed or left handed?
Patient: I am right handed.
Doctor: So, you said that your legs suddenly gave out. What happened exactly? Was it sudden? Or were you noticing some weakness before as well?
Patient: Oh, I noticed weakness in my right leg before as well and sometimes, like, I have to give the support of my arm to actually move it. Sometimes during these episodes I just turn pale and it's like overall weakness. I feel so tired. My husband, he gives me some sugar, three teaspoons, and then it helps a little bit but not completely.
Doctor: So, is your weakness like overall in your legs or it is at any single point?
Patient: It's overall. I remember in one of these episodes I was, like, in an odd fisted posture.
Doctor: Is there any change in your sensations? Like if I touch you, is it like same before or was there any change?
Patient: No, nothing like that.
Doctor: Is there change in vision? Are you seeing double?
Patient: Nope.
Doctor: Any difficulty in swallowing or eating? Any loss of consciousness?
Patient: Nope.
Doctor: Any difficulty in speech? Slurring, or anything like that?
Patient: No.
Doctor: You said that these episodes have been happening for some time, so did you see anyone for those before?
Patient: Nope. It's just that I fall and then fell again last night. I was feeling so weak. Nothing was helping me. That's when, in the morning, my husband brought me to the U I H C hospital for the evaluation on the fifth.

assistant: This 51y/o RHF fell four times on 1/3/93, because her "legs suddenly gave out." She subsequently noticed weakness involving the right leg, and often required the assistance of her arms to move it. During some of these episodes she appeared mildly pale and felt generally weak; her husband would give her 3 teaspoons of sugar and she would appear to improve, thought not completely. During one episode she held her RUE in an "odd fisted posture." She denied any other focal weakness, sensory change, dysarthria, diplopia, dysphagia or alteration of consciousness. She did not seek medical attention despite her weakness. Then, last night, 1/4/93, she fell again ,and because her weakness did not subsequently improve she came to UIHC for evaluation on 1/5/93.
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 traits in the family?
Patient: Oh yeah. Diabetes and high blood pressure runs in my family.
Doctor: Anything else?
Patient: Yeah, my mom suffered with a stroke when she was in her seventies.

assistant: Mother suffered stroke in her 70's. DM and Htn in family.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are you married, ma'am?
Patient: No, I'm divorced.
Doctor: Do you live alone?
Patient: Yes, so I have no support at home, it's difficult.
Doctor: Do you drink or smoke?
Patient: No, I never have.
Doctor: What about more illicit substances?
Patient: No, absolutely not.

assistant: She is divorced. She does not have support at home. She denies tobacco, alcohol, and illicit drug use.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: What is your family medical history, sir?
Patient: We have some heart issues in my family. My sister died during heart surgery two years ago.
Doctor: I am so sorry.
Patient: Thank you. My mom died of a heart attack.
Doctor: How old was she when she passed?
Patient: She was in her seventies? My dad died from a brain hemorrhage. He was only forty nine.
Doctor: Your family had been through a lot of loss.
Patient: Yes, we have.
Doctor: Do you have any siblings that are still living?
Patient: I have another sister. Oh yeah. She is a diabetic.
Doctor: Do you have kids?
Patient: Yes, I have daughter. The only health problem she has is high cholesterol.
Doctor: Do you know of anyone else in the family with neurological disorders?
Patient: No. I don't think so.

assistant: His father died of a cerebral hemorrhage at age 49. His mother died in her 70s from complications of congestive heart failure. He has one sister who died during a cardiac surgery two years ago. He has another sister with diabetes. He has one daughter with hypercholesterolemia. He is unaware of any family members with neurological disorders.
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 any known allergies?
Patient: Not that I know.
Doctor: Any allergies to any drug?
Patient: Nope.

assistant: No known 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: FAM/SOCHX

Dialogue:
Doctor: Are you married?
Patient: Yes, I am.
Doctor: Is the baby your first kid?
Patient: You see, I am a missionary. I have four kids. My eldest is seven years old. Then the other ones are five and three and this one is the youngest. She is just six weeks old.

assistant: Missionary. Married. 4 children ( ages 7,5,3,6 weeks).
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Welcome to A B C D General Hospital. Before we get started, ma'am, how old are you?
Patient: I'm thirty nine, doctor.
Doctor: Great, and what seems to be the problem today?
Patient: I've had this bunion for a good few months now.
Doctor: Is the pain getting worse?
Patient: Absolutely, I can't take it anymore.
Doctor: How have you managed this bunion so far?
Patient: I got some wider shoes, and it's done absolutely nothing.
Doctor: I see.
Patient: Is there surgery or something we can do? I can't take the pain.

assistant: This 39-year-old female presents to ABCD General Hospital with the above chief complaint. The patient states that she has had bunion for many months. It has been progressively getting more painful at this time. The patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.
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?
Patient: I'm twenty eight.
Doctor: So, you are here for the dietary consultation. Is this your first pregnancy?
Patient: No, this is my second pregnancy. I had gestational diabetes with my first one as well.
Doctor: Were you taking any insulin at that time?
Patient: Yes, I used insulin last time as well. I'm just here to understand if diet can help me with my gestational diabetes.
Doctor: Sure.
Patient: My Gynecologist was saying something about ketones, I don't know what they are. She asked me to talk about them with you.
Doctor: Sure, I will explain everything to you. We also have a pamphlet to explain it. Here have a look. You can take it with you.
Patient: Thank you.
Doctor: Are you exercising?
Patient: I walk everyday with my daughter. I go to drop her to school and then back home.
Doctor: How long is the walk to school?
Patient: It takes around twenty minutes on one side. So, everyday it is like forty minutes in the morning and same in the evening around four.
Doctor: Do you drink milk?
Patient: I try to, I know it is a good source of calcium and is very essential especially with my pregnancy, but I am not a big fan of drinking milk.

assistant: This is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy. Patient reports that she had gestational diabetes with her first pregnancy. She did use insulin at that time as well. She does not fully understand what ketones are. She walks her daughter to school and back home each day which takes 20 minutes each way. She is not a big milk drinker, but she does try to drink some.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you know of any family history of kyphosis?
Patient: I'm sorry, what's that?
Doctor: It has to do with rounding of the spine. Does anyone in your family have a rounded posture?
Patient: Actually, yeah, my great grandmother had that, and my mom would talk about my second cousin, he had it too.

assistant: Of kyphosis in great grandmother and second cousin.
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: When did you retire from your job?
Patient: About eleven years ago. It's definitely been nice. I'm able to spend more time with my grandkids.
Doctor: Aw, how many grandkids do you have? And do you live alone?
Patient: I have four grandkids between the ages of two and eleven. I live in the county with my wife and dog. My wife and I've been together for thirty some years now.
Doctor: That's so wonderful to hear.

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

user: Section: GENHX

Dialogue:
Doctor: Good afternoon, young lady.
Patient: Good afternoon, doctor.
Doctor: How has your weight been since your last visit, with the phentermine?
Patient: Well, since the last visit I've gained about a pound.
Doctor: Well, it could be worse, but we're at a plateau, I'd like to see you lose some more per month.
Patient: Yeah, I've been working really hard, but I haven't been able to get the weight down any further so far.
Doctor: What has been your lowest weight?
Patient: My lowest? That was one hundred thirty six. I'm just as frustrated as you are, doctor.
Doctor: Well, if this plateau continues, we should discontinue the phentermine.
Patient: Why is that?
Doctor: It shouldn't be used to maintain your weight, but only to get the weight down. So, if it's not serving that purpose, we shouldn't use it. There's no real benefit there.
Patient: Okay, yes, I agree.

assistant: She is here for a followup on her weight loss on phentermine. She has gained another pound since she was here last. We talked at length about the continued plateau she has had with her weight. She gained a pound the month before and really has not been able to get her weight any farther down than she had when her lowest level was 136. She is frustrated with this as well. We agree that if she continues to plateau she really should not stay on phentermine. We would not want her to take it to maintain her weight but only to help her get her weight down, and she may have really lost any benefit from it, and she agrees. 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: Anyone in the family had a stroke?
Patient: No, no one had a stroke in my family.
Doctor: How about someone in the family with heart disease?
Patient: No one that I can remember.
Doctor: Okay.

assistant: Negative for cerebrovascular accident or cardiac 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:
Patient: You know doctor, I was born in Munich, Germany.
Doctor: Wow, I cannot tell, you speak English so well, no German accent.
Patient: Yeah, I always knew how to speak English even before I was a teen. So, when I moved to America I did not have any language problem.
Doctor: Okay and did you move with your family?
Patient: No, my family moved to the eastern side of the Germany which was occupied by Russia at that time, but I decided to move to America in nineteen fifty seven.
Patient: I had a high school degree from Germany, and I could speak German and English fluently.
Patient: As soon as I landed here in America, I started working. I started as a secretary at a private firm and later did clerical work at I B M. Now I am retired for almost twenty years due to my cancer complications.
Doctor: Your Mesothelioma?
Patient: Yeah.
Doctor: Okay, and who all are there in your family?
Patient: Well currently I am alone without any companion. I am divorced. I have a son who lives in Santa Cruz he has grand children, but I have not seen them, I am trying to get in touch with them. I want to see my grandkids.
Patient: Other than him I have a brother and a sister both are healthy and living their life we don't talk much.
Doctor: Okay.
Doctor: And do you drink or smoke?
Patient: Hm, nothing significant.
Doctor: Any funny drugs like heroine or coke?
Patient: No.
Doctor: Okay.

assistant: Significant for her being without a companion at this point. She was born in Munich, Germany. She immigrated to of America in 1957 after her family had to move to Eastern Germany, which was under Russian occupation at that time. She is divorced. She used to work as a secretary and later worked as a clerical worker at IBM. She stopped working more than 20 years ago due to complications from her mesothelioma. She denies any significant tobacco, alcohol or illicit drugs. She is bilingual speaking, German and English. She has known English from before her teens. She has the equivalent of a high school education in Germany. She has one brother and one sister, both of whom are healthy and she does not spend much time communicating with them. She has one son who lives in Santa Cruz. He has grandchildren. She is trying to contact with her grandchildren.
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 brings you in today? Can you also please state your age?
Patient: Yeah. I am forty five. I've had really bad stomach pain on my right side since last week.
Doctor: On a scale of one to ten, how bad is the pain at its worst?
Patient: I'd have to say a seven.
Doctor: How would you rate it now?
Patient: Oh um it's at a five at the moment.
Doctor: Have you been taking your diabetes medication?
Patient: Micronase?
Doctor: Yes.
Patient: Yeah, I've been taking it every day.
Doctor: Great. Okay, let's try to get to the bottom of this stomach pain.

assistant: The patient is a 45-year-old male complaining of abdominal pain. The patient also has a long-standing history of diabetes which is treated with Micronase daily.
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: Your cholesterol appears to be elevated today. Is this the first time you've been told that your cholesterol levels are high?
Patient: No, unfortunately. I suffer from a few medical problems so maybe that's to blame.
Doctor: I see here that you have diabetes and high blood pressure.
Patient: Right.
Doctor: Does diabetes or high blood pressure run-
Patient: In the family? No, but heart disease does.

assistant: CORONARY RISK FACTORS: History of hypertension, history of diabetes mellitus, nonsmoker. Cholesterol elevated. History of established coronary artery disease in the family and family history positive.
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 was the sleep study?
Patient: Not bad. Although I hafta admit it was difficult staying up in preparation for it.
Doctor: I can imagine. That's always tough. It looks like the eval of your daytime fatigue and insomnia was sent over. Let me print out a copy and we can go over it together. How old are you again?
Patient: I am forty eight.

assistant: This 48-year-old woman returns in followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia.
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 what brings you in today?
Patient: Ugh.
Doctor: I'm guessing you're not feeling too great.
Patient: You got that right. I've had a fever on and off for the past few days.
Doctor: When was the last time you took your temperature?
Patient: Right before I drove here.
Doctor: I see. Did the nurse take your temperature when you came in?
Patient: Yes, she did.
Doctor: Have you been experiencing cold like symptoms, such as cough, nasal congestion, headache, or nausea?
Patient: Um no not really.
Doctor: Have you tried taking any medicine to help with the fever?
Patient: Yeah. I've taken Tylenol and that's helped a bit.
Doctor: Have you had recent sick contacts?
Patient: I don't think so. I live with three other roommates and they seem fine.

assistant: Fever of unknown origin.
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: Anything that has been going on?
Patient: No. What do you mean?
Doctor: I mean anything wrong from head to toe that you would like to add?
Patient: No everything is well. No other problems.
Doctor: Okay. Good.

assistant: He otherwise has a negative 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: GYNHX

Dialogue:
Doctor: How was the procedure?
Patient: It was okay. I was nervous to go under the knife at first, but it turned out better than I expected. Do you know others who've gotten hysterectomies that are near my age?
Doctor: I do, actually. It's a pretty common procedure. I'm glad to hear that you didn't experience any complications.
Patient: Me too.

assistant: Status post hysterectomy.
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: Hello and welcome to our dermatology office. What is the reason for your visit?
Patient: I have these rashes on my arms.
Doctor: Let me take a look. Do you have prior reports about your history?
Patient: Yeah, I do. I gave it to the nurse.
Doctor: Let me go get it really quick. I'm reading the report and it looks like your family is positive for atopy.
Patient: Oh, yeah. We all usually get some type of rash.
Doctor: I see. Do you know if you have psoriasis?
Patient: Uh. What's that's?
Doctor: It's a skin disease that usually has scaly patches.
Patient: Uhm. I don't think so.
Doctor: Great. Before I prescribe you medicine to treat your eczema, are you allergic to any drugs?
Patient: Not that I know of.

assistant: The patient has eczema and a positive atopic family history. No psoriasis. No known 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: FAM/SOCHX

Dialogue:
Doctor: Do you drink?
Patient: Well, I will call myself a social drinker. I would admit that I am addicted to caffeine.
Doctor: How much coffee do you consume each day?
Patient: I would say three to five cups.
Doctor: Any history of sexually transmitted disease?
Patient: Nope.
Doctor: How're your eating habits?
Patient: I would say I am a good eater and follow a healthy diet plan.
Doctor: Do you exercise?
Patient: I walk every day around five miles. Also, I'm very regular in my sprint training.

assistant: Patient admits caffeine use She consumes 3-5 servings per day, Patient admits alcohol use Drinking is described as social, Patient admits good diet habits, Patient admits exercising regularly, Patient denies STD history.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Good afternoon Sir. Do you know how you got here?
Patient: Yes, I passed out and the paramedics brought me to the hospital.
Doctor: Do you have any recollection of the incidences leading up to your loss of consciousness?
Patient: I think I had a seizure and then I passed out.
Doctor: Prior to the episode did you experience any chest pain or shortness of breath?
Patient: No.
Doctor: Any feelings of abnormal heart rhythm?
Patient: No.
Doctor: Do you have any history of any cardiac problems?
Patient: No.
Doctor: How are you feeling now?
Patient: I feel fine.
Doctor: Do you know how old you are?
Patient: I am sixty nine.

assistant: The patient is a 69-year-old gentleman, a good historian, who relates that he was brought in the Emergency Room following an episode of syncope. The patient relates that he may have had a seizure activity prior to that. Prior to the episode, he denies having any symptoms of chest pain or shortness of breath. No palpitation. Presently, he is comfortable, lying in the bed. As per the patient, no prior cardiac history.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Hello Miss Lee how are you?
Patient: I am okay, my arms are troubling me so much.
Doctor: Yeah, I know it's been a longstanding pain in both your arms.
Patient: Yeah, and hands too
Doctor: Can you pinpoint where exactly is the pain?
Patient: Yeah, it's right here in the middle part of arm and my palm.
Doctor: Okay so mostly in the medial part. Tell me do you feel any weakness?
Patient: No, but I do feel this tingling sensation kind of like numbness in my left hand, and it gets worse at night after doing repetitive work.
Doctor: Are you left handed?
Patient: No, I'm right handed
Doctor: Hm, any neck pain?
Patient: Not really, nothing substantial.
Doctor: Can you please tell me your age again?
Patient: I am fifty two.
Doctor: Did you ever have these kind of signs and symptoms in the past?
Patient: Nope!
Doctor: Okay and are you taking anything for pain?
Patient: Ah yes, I am taking Lyrica.
Doctor: Lyrica okay and is it helping?
Patient: Yes, somewhat.
Doctor: Any problem in walking or change in how you walk?
Patient: No.
Doctor: And you are having regular bowel movements any changes?
Patient: Yes, no changes.
Doctor: How about urine, any burning or difficulty peeing?
Patient: No, it's all fine.
Doctor: Okay good. So, the neurological exam we did earlier, I have the results for it.
Patient: And?
Doctor: Well, you were tested positive for Phalen's test on your left hand.
Patient: What does that means?
Doctor: It means that you have something called Carpal tunnel syndrome, which explains your numbness and tingling sensation in your left hand. It also explains your pain in the middle part of your hand as it's caused due to pinching or compression of a nerve called median nerve.
Patient: Oh, how did that happen?
Doctor: Well, it's possible that your repetitive hand motion could have caused it or sometimes it's just the anatomy of your wrist.
Patient: Oh, that explains my increased pain in the night after work.
Doctor: Yeah.
Patient: Anything else came in the neuro test?
Doctor: No, rest of your neurological exam was normal.
Patient: Okay. I am worried now.
Doctor: Don't worry we are here.
Patient: Thank you!

assistant: The patient is a 52-year-old right-handed female with longstanding bilateral arm pain, which is predominantly in the medial aspect of her arms and hands as well as left hand numbness, worse at night and after doing repetitive work with her left hand. She denies any weakness. No significant neck pain, change in bowel or bladder symptoms, change in gait, or similar symptoms in the past. She is on Lyrica for the pain, which has been somewhat successful. Examination reveals positive Phalen's test on the left. Remainder of her neurological examination is normal.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Have we gone over your survey results from your last visit?
Patient: No, do you have those results with you right now?
Doctor: Yes, I do, they show that you have anxiety disorder.
Patient: That makes sense, thank you for sharing that with me.

assistant: Significant for anxiety 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: CC

Dialogue:
Doctor: I see here that you've been having some chest pain. Where along the chest?
Patient: It's mostly on the left side.
Doctor: When did it start?
Patient: Um a few days ago.
Doctor: How'd you describe the pain?
Patient: Kinda dull.
Doctor: Any other symptoms with the pain, such as shortness of breath?
Patient: Not really, no.
Doctor: How long does the pain usually last?
Patient: For a few minutes. It comes and goes.
Doctor: Have you taken anything for the pain?
Patient: I've taken some Advil, but it doesn't seem to help.
Doctor: Have you had similar pain in the past?
Patient: No, I don't think so.
Doctor: And you had surgery on your abdomen five days ago, correct?
Patient: Yes. Do you think the pain is related?
Doctor: I'd like to run some tests and get you in for a CAT scan to see what's going on.

assistant: For evaluation of left-sided chest pain, 5 days post abdominal 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: PASTMEDICALHX

Dialogue:
Doctor: It looks like he has a history of high blood pressure, high cholesterol, and Afib.
Guest_clinician: Does he see a cardiologist for his Afib?
Doctor: Not according to his chart. I'll see if I can call his emergency contact to confirm.
Guest_clinician: Okay. Keep me posted.

assistant: Per the emergency room record, significant for atrial fibrillation, hypertension, and hyperlipidemia.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you smoke or drink alcohol?
Patient: No, I do not smoke or drink alcohol.
Doctor: How about drugs?
Patient: Nope, I have never.
Doctor: Who do you live with?
Patient: Just my family.

assistant: The patient is a nonsmoker. Denies any alcohol or illicit drug use. The patient does live with his family.