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: Good afternoon, ma'am.
Patient: Good afternoon, doctor.
Doctor: So, what do you do for a living?
Patient: Right now, actually, I'm not working.
Doctor: That's okay, I'm not here to judge. Are you married?
Patient: No, I'm happily single right now.
Doctor: Good for you, do you have any kids?
Patient: No, I don't have any, its just me.
Doctor: Do you drink or smoke?
Patient: No, I don't do any of that.
Doctor: Good, and do you use anything harder? Like illicit drugs?
Patient: No, I absolutely do not.
Doctor: Good, and with ten being the most stressful day every, how would you rate your stress level out of ten?
Patient: Today, I'd say its about an eight out of ten.

assistant: The patient is not working. Rates her stress level as an 8/10. She is single with no children. Does not smoke, drink, or utilize illicit substances.
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: Hello. How are you doing today?
Patient: My head has been hurting a lot.
Doctor: I see. Did the nurse come in and ask you questions about past medical history?
Guest_clinician: Sorry, Doctor. I was looking for you. I reviewed his history with him, and nothing has changed.
Doctor: Perfect. Let's do some tests to see why your head has been hurting.
Patient: I'm ready for less pain. Let's go.

assistant: otherwise unchanged.
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: We're going to check around your knee now.
Patient: Okay, sounds good.
Doctor: Looks like your deep tendon reflexes are the same on both legs. Sensation seems great and intact.

assistant: NEUROLOGIC: Deep tendon reflexes were symmetrical at the patellar area. Sensation was grossly intact by touch.
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 something about your family? Any illnesses in family?
Patient: My dad's mom has diabetes and hypertension and my dad's dad had emphysema and he was a smoker.
Doctor: Okay.
Patient: Yeah.
Doctor: Is there any history of death of child who was less than a year maybe?
Patient: No, there isn't.
Doctor: Okay. That's great. No illnesses for small children?
Patient: No.

assistant: Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker. There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.
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: Alright, I am looking at your urine report and it confirms what I was suspecting. You have a urinary tract infection.
Patient: I kind of knew it was a U T I. I have had it before, but nothing this painful and severe. I feel like I am going to die!
Doctor: Oh yes, it is because you got something called as acute cystitis and its usually very painful and can cause some serious complications.
Patient: Well, is it because of my diabetes?
Doctor: I am afraid I don't have better news for you, but your diabetes is out of control. It's way too high and you must be really careful. Are you taking your medicines?
Patient: Yes!
Doctor: How bout diet?
Patient: Yeah, sometimes I don't care about my diet.
Doctor: Well, you must watch your diet, you can't just be careless. I am going to change your diabetes medication. And let's start you on the antibiotic that should give you relief. Also stay hydrated drink plenty of fluids it will help you flush the infection out.
Patient: Alright, thank you!
Doctor: Take care.

assistant: Diabetes type II uncontrolled. Acute cystitis.
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: Good morning, ma'am.
Patient: Good morning, doctor.
Doctor: Before we begin, I just have a few questions. Do you remember what illnesses you had as a child?
Patient: Yes, I got a few. I had strep throat, mumps, and, um, chickenpox growing up.

assistant: Childhood Illnesses: (+) strep throat (+) mumps (+) chickenpox
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! I am Doctor Sherman.
Patient: Hello! It is nice to meet you.
Doctor: It looks like your P C P sent you to us for a possible prostate problem.
Patient: Yes. I am nervous.
Doctor: Do not be nervous. We will start with discussing the symptoms you have been experiencing, a physical exam and then we will get a urine sample if you are able.
Patient: Okay.

assistant: Urology.
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 are you taking for allergies?
Patient: Claritin.
Doctor: Okay.
Patient: For my allergic rhinitis.

assistant: Claritin for allergic rhinitis.
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 had a heart attack and passed away at sixty one.
Doctor: I am so sorry to hear that.
Patient: Thank you.
Doctor: Do you know of any other major health conditions in your family?
Patient: No. None that I know of. Everyone is relatively healthy.
Doctor: That's good.

assistant: Father died, MI age 61.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Hello, sir how are you feeling today?
Patient: I feel terrible. Very sick and I can barely move. I feel so weak.

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

user: Section: IMAGING

Dialogue:
Doctor: So, we looked at your previous blood work results, now let me see what these reports say from today's C B C exam.
Patient: Sure.
Doctor: Okay so your hemoglobin levels look within range, white counts are thirteen point three, then seven point six lymphocytes and twenty six thousand platelets.
Doctor: Okay?
Patient: Okay.

assistant: The patient's CBC results from before were reviewed. Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000.
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 surgery have you had in past? Anything big or small?
Patient: I had a C section for my kiddo and one D and C.
Doctor: Okay.

assistant: C-section and D&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: Hello again!
Patient: Hi!
Doctor: The results from you M R I showed nothing concerning. The growth factors were normal with normal cell function and no signs of decreased blood supply to the brain.
Patient: That's great news.
Doctor: Yes it is.

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

user: Section: GENHX

Dialogue:
Doctor: So, I understand that you had a fall.
Patient: Yes. I did fall.
Doctor: What happened?
Patient: I don't really know. I have balancing problems. I have been to my P C P for this issue a few days ago. I saw her about a week and a half ago because I had another fall. Maybe around late December since today is January seventh. I have been having trouble with my right hand. It is like I am clumsy on my right side. I ended up falling because my right hand missed the railing when I grabbed it to head up the stairs.
Doctor: Are you left or right handed?
Patient: Right.
Doctor: Can you tell me a little bit more about the trouble that you are having with the right hand? Is it localized to the right hand?
Patient: Yes, it is only on my right side. It is like the right side of my body is weak and it has been getting worse.
Doctor: How long has this issue been progressing for?
Patient: About two years.
Doctor: Have you experienced any blurred vision or visual disturbances?
Patient: Yes. Every once and a while.
Doctor: How old are you?
Patient: I just turned fifty eight last week.
Doctor: Happy belated birthday!
Patient: Thank you!
Doctor: Did your P C P have any bloodwork or imaging done?
Patient: Yes, she did. She did both. She said she would send my records over.
Doctor: Oh. I see it here! Did Doctor Madison discuss the results of your H C T and the M R I yet?
Patient: No.
Doctor: Okay. The results showed clinoid masses. This explains that problems that you have been having with your right side, your balancing problems, and the visual disturbances. With only the M R I I cannot tell if the masses are malignant or not.
Patient: So, are the masses cancer?
Doctor: I don't know yet. I will have to run some more tests and potently have to do a biopsy.
Patient: Okay.

assistant: This 58 y/o RHF had a 2 yr h/o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations. She was evaluated by a local physician several days prior to this presentation (1/7/91), for clumsiness of her right hand and falling. HCT and MRI brain revealed bilateral posterior clinoid masses.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you smoke?
Patient: Yes, I do.
Doctor: How much? I mean can you tell me approximate amount?
Patient: Yes sure, I smoke half a pack a day.
Doctor: How about alcohol and drugs?
Patient: No, I do not drink or use. I have a five month old baby.

assistant: She had a baby five months ago. She smokes a half pack a day. She denies alcohol and 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: GENHX

Dialogue:
Doctor: With ten being the worst pain imaginable, how would you rate your pain today out of ten, ma'am?
Patient: Well, out of ten, I'd say it's about a seven.
Doctor: How would you describe your pain?
Patient: Um, I'd say it's deep, and it really aches.
Doctor: Where is your pain located?
Patient: It's in my right lower back, and then into my butt.
Doctor: What activities make your surgery worse?
Patient: I can't go up and down stairs without a lot of pain, and it hurts when I sit for a long time, like when I drive.
Doctor: Before this pain, how would you describe your activity level?
Patient: I was very active before all this started.
Doctor: Are you able to do any of your prior activities?
Patient: Not really, I'm having a lot of problems with stuff around the house, like all the chores and projects I used to be able to do.

assistant: The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse. The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region. Aggravating factors include stairs and prolonged driving, as well as general limitations with home tasks and projects. The patient states she is a very active individual and is noticing extreme limitations with ability to complete home tasks and projects she used to be able to complete.
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 in!
Patient: Thank you.
Doctor: Let us get a little background. What is your medical history?
Patient: I have some memory loss problems.
Doctor: What kind of memory problems?
Patient: Well, I have seizures.
Doctor: Do you know what kind of seizures that you have?
Patient: I have temporal lobe seizures.
Doctor: Do you have any other health conditions?
Patient: I also have high blood pressure.
Doctor: Okay.

assistant: Significant only for hypertension and left temporal lobe epilepsy.
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: Did you have any medical issues?
Patient: Nope.
Doctor: What about surgery.
Patient: No, I never had a surgery.

assistant: She has undergone no surgical procedures.
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: You are not allergic to anything?
Patient: No, I am not.
Doctor: Any food or other pollen?
Patient: No, I am not allergic to anything.
Doctor: Great!

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: MEDICATIONS

Dialogue:
Doctor: April twenty two three we checked your list of medications.
Doctor: We saw that it lifts up in the morning and evening.
Doctor: Yeah.
Patient: Yeah.

assistant: Her list of medicines is as noted on 04/22/03. There is a morning and evening lift.
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 is the baby?
Guest_family: He is twenty one months old.
Doctor: What brings you here today?
Guest_family: I have concerns about his motor development. Many times he seems to have lazy eyes and sometimes I can notice his jaw quivering.
Doctor: How was your pregnancy?
Guest_family: I had no complications in my pregnancy with him. My labor was very spontaneous, and it was a normal delivery.
Doctor: Is this the only child?
Guest_family: No, I have two more kids.
Doctor: How much did he weigh at birth?
Guest_family: He was around eight pounds and ten ounces.
Doctor: Did you remember his milestones?
Guest_family: Yes, I have all of it written down for all of my three kids and I brought this with me. He sat on his own by seven months. He was able to stand by eleven months and crawled around sixteen months but he was not walking until eighteen months.
Doctor: What issues are he facing right now?
Guest_family: He falls a lot. He cannot walk properly. He is kind of in toeing on his left. He's able to feed himself properly. He also throws, um, he picks up the things and throws them. His upper body looks strong.
Doctor: How about his speech? How many words do you think he knows?
Guest_family: He knows more than twenty words for sure.
Doctor: Is he able to speak two word phrases?
Guest_family: Yes. He says things like ,”give me,” and, “come here.”
Doctor: Any other unusual behavior that you noticed? Any seizures or just the quivering movement of the jaw?
Guest_family: No, it was only this and we have noticed this since birth. I don't know if it is related but I did notice that his left eye deviates outside.

assistant: This 21 month old male presented for delayed motor development, "jaw quivering" and "lazy eye." He was an 8 pound 10 ounce product of a full term, uncomplicated pregnancy-labor-spontaneous vaginal delivery to a G3P3 married white female mother. There had been no known toxic intrauterine exposures. He had no serious illnesses or hospitalizations since birth. He sat independently at 7 months, stood at 11 months, crawled at 16 months, but did not cruise until 18 months. He currently cannot walk and easily falls. His gait is reportedly marked by left "intoeing." His upper extremity strength and coordination reportedly appear quite normal and he is able to feed himself, throw and transfer objects easily. He knows greater than 20 words and speaks two-word phrases. No seizures or unusual behavior were reported except for "quivering" movement of his jaw. This has occurred since birth. In addition the parents have noted transient left exotropia.
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 back into the clinic today?
Patient: I have been having some severe bruising. I have been taking Coumadin for three months now. Am I taking to much Coumadin?
Doctor: You are taking a normal start dose. Some people do not metabolize the medication as well as others. I would like to get you tested for hypersensitivity. After we get the test results back, we will be able to adjust your dosage accordingly.
Patient: Okay.

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

user: Section: PASTMEDICALHX

Dialogue:
Doctor: I'm reviewing my notes from your last visit. Your last visit was on May tenth two thousand four, correct?
Patient: Yes, that's right.
Doctor: Has there been any change since your last visit?
Patient: Well, I'm having some increased paranoia.
Doctor: Have you been treated, and are you taking medicine for this?
Patient: Yes, and it's actually gotten a lot better with the medicine another doctor gave me.

assistant: Reviewed from 05/10/2004 and unchanged other than the addition of paranoia, which is much improved on her current medications.
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 just met with one of my patients whom I believe has pertussis.
Guest_clinician: Second case of the day. What's their name and date of birth?
Doctor: Hm give me a second to pull up their information.

assistant: Public Health Department was notified of a case of suspected pertussis.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Have you ever had psychiatric or psychological treatment?
Patient: Uh no, no treatments whatsoever. I mean I do find myself in low moods every now and again when I'm dealing with certain stressors, but the decreased moods rarely ever long lasting.

assistant: The patient denied any history of psychological or psychiatric treatment. He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: IMMUNIZATIONS

Dialogue:
Doctor: Do you remember when your last flu vaccine was?
Patient: I don't remember what month, but it was in nineteen ninety nine.
Doctor: Good, and do you remember your last pneumonia vaccine?
Patient: Let me look at my notes here, um, it was in nineteen ninety six.
Doctor: Thank you, now, tell me more about your parents. Do you know their medical histories?
Patient: Let me think, my dad is still around, he had a stroke. Oh yeah, and he has high blood pressure.
Doctor: How old is your father?
Patient: He's seventy nine now.
Doctor: Good, what about your mother?
Patient: She died when she was seventy four, she had heart failure and emphysema.
Doctor: I'm sorry to hear that. Do you have any brothers or sisters?
Patient: Thank you doctor, no, its just me and my Dad now.

assistant: Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996. Family Medical History: Father age 79, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 74. No brothers and sisters.
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 you doing today, ma'am?
Patient: I'm doing just fine.
Doctor: Any kind of alcohol consumption?
Patient: Nope.
Doctor: Have you ever taken any kind of illegal drugs?
Patient: Nope.
Doctor: What about smoking?
Patient: No.
Doctor: Are you still working?
Patient: No, sir. I had issues with my knees, and they had to put in the new ones. I was kind of disabled and that's why I retired.

assistant: The patient is retired on disability due to her knee replacements. She does not smoke, drink or use any illicit drugs.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ROS

Dialogue:
Doctor: Do you have any chest pain?
Patient: No, I don't.
Doctor: Any breathlessness?
Patient: Yes, I do get breathless only when I have to do some form of exertion like walking a long time or running.
Doctor: Okay. How about any bowel issues?
Patient: No, I don't have any stomach problems except I have to go frequently to use a bathroom.
Doctor: Okay frequency. How about any prolonged bleeding issues or anything like that sort?
Patient: No nothing like that.

assistant: He denies any chest pain. He admits to exertional shortness of breath. He denies any GI problems as noted. Has frequent urination as noted. He denies any bleeding disorders or bleeding 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: Does she lives with anyone?
Guest_family: Yes, we all stay together, so just the immediate family. My parents, me and my sister.
Doctor: Okay.

assistant: She lives with her parents.
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 specific family medical history that I should be aware of?
Patient: No.
Doctor: Anyone in your family, even grandparents, if you know them, did they have diabetes or high blood pressure?
Patient: No.
Doctor: Anyone else sick at home?
Patient: No.

assistant: Noncontributory. No one else at home is sick.
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 has high blood pressure, and she had a stroke last year.
Doctor: Is your mother still with us after the stroke?
Patient: Yeah. She is doing well.
Doctor: Good. What about your father's medical history?
Patient: My father died in a car accident, when he was forty.
Doctor: I am so sorry to hear that.
Patient: Thank you.

assistant: Mother is alive and has a h/o HTN and stroke. Father died in motor vehicle accident at age 40 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: FAM/SOCHX

Dialogue:
Doctor: Anyone in your family have a history of drug or alcohol abuse?
Patient: No.
Doctor: Any other medical conditions that might run in your family?
Patient: Nope.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you drink?
Patient: Like, every day?
Doctor: No, just in general.
Patient: No, I don't drink at all.
Doctor: Do you smoke?
Patient: No, I don't do that at all, either.

assistant: The patient does not smoke nor drink alcohol.
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: Any drug allergies?
Patient: Ah yes, I am allergic to... what's the name of the drug? It's called Napro-
Doctor: Naprosyn?
Patient: Yes, Naprosyn.

assistant: Naprosyn.
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: PLAN

Dialogue:
Doctor: Hi, how old are you madam?
Patient: I am ninety three. I am a super duper old Swedish woman.
Doctor: Ha! Not so old okay!
Patient: I had vomiting episodes and I am feeling very nauseous.
Doctor: Oh I am so sorry to hear that.
Patient: I have pain in urination too, I think I might have the U T I?
Doctor: Let's see here. So you already have a right hip issue, bone disease, hypertension, depression, and heart rhythm disorder for a long time.
Patient: Yes that is correct.
Doctor: Let me see what we can do here.
Patient: Thank you doctor.

assistant: The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.
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: No, never!
Doctor: Did you ever smoke?
Patient: No.
Doctor: How about drugs? Marijuana or anything?
Patient: Well, I always stayed away from drugs.
Doctor: Good. And what is your living arrangement? Do you stay with your kids?
Patient: I live at my place. My kids visit me but mostly I live alone.
Doctor: Okay.

assistant: No history of smoking, alcohol, or drug use. She lives at home.
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, how old are you?
Patient: Hello Doctor, I'm fifty four years old.
Doctor: What gender do you identify with?
Patient: I identify as a female.
Doctor: Thank you. What symptoms are you experiencing in your right hand?
Patient: I have numbness and tingling in my right hand.
Doctor: Are there any specific fingers that you feel it in?
Patient: I really feel it in my fifth, fourth, and third fingers.
Doctor: What kind of treatments have you done for this pain?
Patient: I've taken antiinflammatories, stayed away from sports and stuff like that, and rested.
Doctor: Has this helped at all?
Patient: No, not at all, its still numb and tingling.
Doctor: This sounds like carpal tunnel, there's a quick, minimally invasive surgery I can do on this hand, since it hasn't responded to nonoperative treatments. I think that'll really help.
Patient: I'd like to do that, what's the name of the procedure?
Doctor: Its called a carpal tunnel release.

assistant: This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ROS

Dialogue:
Guest_family: Congestion and cough.
Doctor: Oh, how long?
Guest_family: It's been three weeks now.
Doctor: Okay.
Guest_family: He has been like this for so long, but nothing else.
Doctor: How about fever nausea vomiting diarrhea?
Guest_family: No fever, no vomiting, nothing else.
Doctor: Okay great.

assistant: He has been congested for about three weeks ago. Coughing now but no fevers. No vomiting. Review of systems is otherwise negative.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: What do you do? Are you working or in school?
Patient: I am in school.
Doctor: Good.
Patient: Thanks.

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

user: Section: GENHX

Dialogue:
Doctor: Do you have any children, ma'am?
Patient: Yes, I have a wonderful baby girl at home.
Doctor: Wonderful, were there any complications with your pregnancy or delivery?
Patient: Nope, everything went very smooth. I'm thankful.
Doctor: Good, have you ever been hospitalized for any issue?
Patient: No, thankfully.
Doctor: Good, so I can assume you've never had surgery?
Patient: Correct, I never have.

assistant: Pregnancy and delivery with no complications. He has no history of hospitalizations or surgeries.
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: Any past surgeries that I should know of?
Patient: I had a hip replacement years ago.
Doctor: Both hips?
Patient: My left.
Doctor: Total?
Patient: Yeah.
Doctor: Got it.
Patient: I also had my uterus and appendix removed. I was young when I had my appendix taken out.
Doctor: Do you happen to remember who did your most recent surgeries?
Patient: Wish I did. I'd have to look back at my records and get back to you. I have everything at home.
Doctor: That's no problem. I should be able to look it up from my end, too.

assistant: Include left total hip replacement many years ago, history of hysterectomy, and appendectomy in the young age.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ROS

Dialogue:
Doctor: Where do you live?
Patient: I live with my mother around the corner where the Whole Foods is. I have been there for a few years now.
Doctor: Are you the mother of the patient?
Guest_family: Yes, I'm the mother.
Doctor: How are you dealing with everything?
Guest_family: We just want what is best for him. We want to support him in every possible way. He has only one elder sister. She lives in Texas and she also wants the same for him. Before he started living with us, he has been living in the A B C D places and some were in very bad condition. He was not striving there. That's why we asked him to move in with us.

assistant: PSYCHIATRIC: The patient lives with his mother and has been staying with her for a few years now. We have talked to her. She is very supportive. His only sister is also very supportive of him. He has lived in the ABCD houses in the past. He has done poorly in some of them.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: MEDICATIONS

Dialogue:
Doctor: Are you taking any medications?
Patient: Yes, I am taking Accutane for my acne issues.
Doctor: Okay, any other medicines?
Patient: No, just that.
Doctor: Okay.

assistant: Accutane and takes no other medications.
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 any history of surgeries, sir?
Patient: The most recent was seven years ago. I had a craniotomy. I had a brain hemorrhage and there was bleed inside and outside the brain that they had to fix.
Doctor: How was the recovery for that?
Patient: I took a while but the doctors said I had a normal recovery time.
Doctor: That is good. Have you had any other surgeries?
Patient: I had surgery on my leg for a fracture. They put some pins in my leg.
Doctor: Okay.
Patient: I had some kind of surgery done on my stomach when I was a kid. I am not sure what the surgery was. All I know is that it was a very common procedure with no complications.
Doctor: Okay. Is that all?
Patient: Yep. That's it.

assistant: 1. He has a surgery on his stomach as a child. He does not know the type. 2. Surgery for a leg fracture. 3. Craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Do you have any past medical problems that I should know about?
Patient: Well, what exactly do you mean by that, doctor?
Doctor: Well, it could be anything from A D H D to depression to epilepsy.
Patient: Oh, no. I don't have anything like that.

assistant: No significant past medical problems.
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, lets talk about your family, anybody in your family have any neurological problems?
Patient: No, I don't think so, my parents did experience some memory loss but that was when they were in their nineties. And I am assuming it was mostly from the old age rather than any neuro problem.
Doctor: Yeah, that is true. And how about your brothers and sisters, do you have any?
Patient: Oh yeah, I have five siblings and they are pretty healthy! I mean all of them are doing good, no one has any memory issues as far as I know or any neuro related illness.
Doctor: Okay.

assistant: Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his 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: PLAN

Dialogue:
Patient: Um, do I have to follow some special or soft diet?
Doctor: No, nothing like that. You can have a normal diet. Whatever you like to eat.
Patient: At this age, my diet is very limited. I am going to be eighty-two next month.
Doctor: Well, I don't think you need to restrict your diet. You can follow your regular diet.
Patient: Alright, thank you.

assistant: Regular for age.
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 migraine headaches run in the family?
Patient: My mother gets migraines and she told me that it runs on her side of the family.
Doctor: Any family history of blood clots?
Patient: No.

assistant: Migraine headaches on maternal side, including her mother. No family history of thrombosis.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are you married?
Patient: I was, but my husband died thirty years ago.
Doctor: Are you working?
Patient: Nope.
Doctor: What is your highest degree?
Patient: I did high school. I was living alone for fifteen years until December of ninety four.
Doctor: How is your living situation now? Who is taking care of you?
Patient: My daughters have started taking care of me on a shareable basis.
Doctor: Do you smoke? Or drink or have ever used any drugs.
Patient: Nope.

assistant: She attained a High School education and had been widowed for over 30 years. She lived alone for 15 years until to 12/94, when her daughters began sharing the task of caring for her. She had no history of tobacco, alcohol or 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: Do you smoke, or have you smoked in the past?
Patient: Yeah, I quit two years ago. But before that I used to smoke two packs per day. I first started smoking as a teenager.
Doctor: Do you drink at all?
Patient: I used to drink six packs of beer plus two additional drinks a day for many years. Good news is that I've been dry for two years now.
Doctor: Any illicit drug use, such as cocaine, marijuana or heroin?
Patient: No none of that.

assistant: 2ppd smoker since his teens; quit 2 years ago. 6-pack beer plus 2 drinks per day for many years: now claims he has been dry for 2 years. Denies 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: GENHX

Dialogue:
Doctor: Hello, miss. How are you doing today? It looks like we are evaluating C O P D and emphysema.
Patient: Yes, the last time I was seen in Pulmonary Medicine Clinic was March two thousand and four.
Doctor: It has been quite some time. How are you feeling?
Patient: I have actually been hospitalized for psychiatric problems and now live in a nursing facility. Things have not been too great. I don't like living there.
Doctor: I understand the frustration. When you live in a nursing facility you lose a lot of your freedom.
Patient: I want to live back in my apartment, but I know I am too ill to care for myself.
Doctor: In spite of all of that how are your respiratory issues?
Patient: I feel pretty stable. I still have shortness of breath when I do activities, but with my condition I feel like that is something I will have to live with.
Doctor: Unfortunately, that is the nature of the disease. I am happy to see that the pulmonary disease has not changed significantly since your last visit.
Patient: The only thing that seems to have changed is that I have a small cough and produce some mucus.
Doctor: Okay. Do you have any fever or chills?
Patient: No, none of that.
Doctor: Do you experience any chest pains? I want to check especially since you have been coughing up some mucus.
Patient: No, I luckily do not have any chest pains.

assistant: The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. She was last seen in the clinic in March 2004. Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility. She is very frustrated with her living situation and would like to return to her own apartment, however, some believes she is to ill to care for herself. At the present time, respiratory status is relatively stable. She is still short of breath with activity, but all-in-all her pulmonary disease has not changed significantly since her last visit. She does have occasional cough and a small amount of sputum production. No fever or chills. No chest pains.
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: You can continue working, I just want you to be careful.
Patient: Thanks Doctor. I will be.
Doctor: Great.

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

user: Section: GENHX

Dialogue:
Doctor: Can you confirm your age for me, ma'am?
Patient: Sure, I'm fifty six years old.
Doctor: Great, so what brings you in to see me today?
Patient: Um, I'm peeing a lot, and I'm having a little bit blood in that urine as well.
Doctor: Have you ever had a cystoscopy?
Patient: Yes, it was unremarkable, that's what they told me.
Doctor: When are your episodes for the most part?
Patient: Um, usually during the day. I don't usually have them at night.
Doctor: Are you having any pain with urination?
Patient: No, no pain.
Doctor: Aside from the little bit of blood, can you tell if there's any pus in your urine?
Patient: No, I don't have any of that, it's just the little bit of blood.
Doctor: Have you taken any medications for this?
Patient: Um, I had Ditropan, and it didn't do very well.
Doctor: Well, this ultrasound of the kidney is also unremarkable, so at this time I think we should try a different medication.

assistant: The patient is a 56-year-old noted to have microscopic hematuria with overactive bladder. Her cystoscopy performed was unremarkable. She continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night. No gross hematuria, dysuria, pyuria, no other outlet obstructive and/or irritative voiding symptoms. The patient had been previously on Ditropan and did not do nearly as well. At this point, what we will try is a different medication. Renal ultrasound is otherwise unremarkable, notes no evidence of any other 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: GENHX

Dialogue:
Doctor: Hello sir, how are you?
Patient: I don't know, I don't know whether I am good, or my problem is getting worse and that is the reason I got myself to your clinic for a neurological consult.
Doctor: Hm, don't worry! We will take care of you, let me start by taking some details.
Patient: Sure!
Doctor: So were you referred by someone or-
Patient: Oh, no I referred myself to your clinic.
Doctor: Okay. And what is your age?
Patient: I am sixty four years young!
Doctor: Ah, that's clever, you certainly look very young. And which is your dominant hand? Are you left handed, or right?
Patient: I am right handed.
Doctor: So, tell me what is going on with you?
Patient: Well, lately I am having difficulty remembering names and phone numbers or even events.
Doctor: Well, it's not uncommon.
Patient: I know, but I am usually very good at remembering things. I would have not worried that much, but it was brought to my attention by my clerical staff.
Doctor: Oh, okay. What do you do?
Patient: Well, I was the catholic priest at my parish, like we have our own small administrative district and church.
Doctor: Okay, and when did you notice first that you are forgetting things?
Patient: Around twelve months back.
Doctor: And did it cause any problem at work or any mishaps?
Patient: No, not at all! No social or professional faux pas whatsoever.
Doctor: Okay, I have my notes let me put the date, oh what is the date-
Patient: It's twenty eighth of February.
Doctor: Thank you!

assistant: This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the Neurology clinic on his own referral.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: DISPOSITION

Dialogue:
Doctor: All right, you can go home now.
Patient: Thank you doctor.
Doctor: You can stay at your friend's place and make sure to take good care of yourself.
Patient: Yes.
Doctor: Make sure you follow up with Doctor X on Monday or Tuesday. I know that Doctor Y already discussed his plans. Continue taking your medicines except Prozac. Okay?

assistant: She is being discharged to home. She will stay with a friend for a couple of days. She will be following up with Dr. X on Monday or Tuesday. Apparently Dr. Y has already discussed the situation and the plan with her. She will continue on her usual medications except for discontinuing the Prozac.