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: How old are you now?
Patient: I am sixty five. My kids just through me a surprise birthday party last week.
Doctor: Oh wow! That is so nice. Happy belated birthday.
Patient: It was nice.
Doctor: It looks like you are here today for a recheck for the prostatitis.
Patient: Yeah.
Doctor: I see you have been followed by Doctor Mathis.
Patient: Yes.
Doctor: How often do you see him?
Patient: He has me coming in about every three or four months.
Doctor: Excellent. And the last time I saw you was in May two thousand and four.
Patient: Has it been that long?
Doctor: Yeah, it has. Okay. You are here to discuss some libido problems?
Patient: Sadly, yes.
Doctor: How long have you been having these difficulties?
Patient: I noticed the change when I started taking the Proscar.
Doctor: That is a common side effect that some men experience from Proscar. Have you tried any medication to help bring back your libido?
Patient: I take Viagra sometimes.
Doctor: Does it help at all?
Patient: There is some improvement.
Doctor: How many times a night do you get up to relive yourself now?
Patient: I still get up about three to four times.
Doctor: Okay, so still often.
Patient: Yes, but I have not had any U T Is since I have been on the Proscar.
Doctor: That is good news.

assistant: The patient is a 65-year-old man with chronic prostatitis who returns for recheck. He follow with Dr. XYZ about every three to four months. His last appointment was in May 2004. Has had decreased libido since he has been on Proscar. He had tried Viagra with some improvement. He has not had any urinary tract infection since he has been on Proscar. Has nocturia x 3 to 4.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are you married, sir?
Patient: Yes, I am, Doctor:
Doctor: Is this your only marriage?
Patient: Well, no. I've been married three times now.
Doctor: If you don't mind my asking, how long was your longest marriage?
Patient: I don't mind at all, my longest was two years.
Doctor: Do you have any children, sir?
Patient: Yes, I have two.
Doctor: How old are they, sir?
Patient: They're both fifteen, they're twins, obviously. They're my wife's dependents, though.
Doctor: Okay, thank you. Did you go to college, sir?
Patient: Yeah, I have my bachelor's. I got the military to pay for it.
Doctor: How long were you in the military?
Patient: I did six years, sir. I was honorably discharged.
Doctor: Where are you working currently.
Patient: I've worked at Purdy Correctional Institute, you know, the one in Gig Harbor? I've worked there for nineteen years.

assistant: Marital Status and Dependents: The patient has been married three times; longest marriage is of two years duration. He has two children. These dependents are ages 15 and twins and are his wife's dependents. Education: The patient has bachelor's degree. Military History: He served six years in the army and received an honorable discharge. Work History: He has worked at Purdy Correctional Institute in Gig Harbor for 19 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: ASSESSMENT

Dialogue:
Doctor: So, looks like you have stones in your C B D. I am not hundred percent sure but most likely its stones.
Patient: C B D?
Doctor: Yeah, short for common bile duct. It's a small tube like structure which connects your liver duct and gallbladder.
Patient: Oh!
Doctor: Yeah, and because of that you have inflammation in your gallbladder.
Patient: Oh, I see.

assistant: Choledocholithiasis, ? cholecystitis.
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: Has he had a blood transfusion in the past?
Doctor: No, this is his first one.
Guest_clinician: Okay, got it.

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

user: Section: GENHX

Dialogue:
Doctor: Can you tell me more about your son, please?
Guest_family: Sure, he's ten years old now.
Doctor: How long has he used his walker?
Guest_family: Well, he's been using that since he started walking.
Doctor: How old was he when he started walking?
Guest_family: He was about a year old.
Doctor: Good, what seems to be the problem today?
Guest_family: He keeps complaining about the back of his legs being tight.
Doctor: Can you sit on the table, young man? Yes, I'm bending his legs, we call this the popliteal angle, and both sides flex to only about twenty.
Guest_family: Where should that be normally?
Doctor: He should be able to get to ninety.
Guest_family: What can we do about this?
Doctor: I think we should do surgery on this leg. How does he walk? Can I see?
Guest_family: Well, just look at him.
Doctor: Yes, he does not walk with a crouched pattern, but he is toe walking.
Guest_family: Can we correct that instead of the hamstring tightness?
Doctor: Well, I believe he should have surgery on the hamstring, as well.
Guest_family: Okay, right now we want to do surgery to fix his walking. What are the risks of infection?
Doctor: They're low, historically, they're less than one percent. The risks include anesthesia, infection, bleeding, changes in sensation and the motion of walking, and it may also not always cure the toe walking. There is also possible stiffness after wearing the cast and other cast issues.
Guest_family: Okay, and will be under anesthesia during this? Is this worth it?
Doctor: Absolutely, he won't feel a thing. It is worth it because the chances of the risks happening are low.
Guest_family: Yes, we'd like to do the procedure. Let me text my husband really quick. Okay, yes, my husband agrees.

assistant: The patient is a 10-year-old boy who has been a toe walker since he started ambulating at about a year. The patient had some mild hamstring tightness with his popliteal angle of approximately 20 degrees bilaterally. He does not walk with a crouched gait but does toe walk. Given his tightness, surgery versus observation was recommended to the family. Family however wanted to correct his toe walking. Surgery was then discussed. Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to resolve toe walking, possible stiffness, cast, and cast problems. All questions were answered and parents agreed to above surgical 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: ROS

Dialogue:
Doctor: Did you ever have any reaction to any medication given? Any known allergies?
Patient: No.
Doctor: Was there any swelling where your lymphnodes are?
Patient: No.
Doctor: Was there ever any complaint of abnormal lymph nodes?
Patient: No.

assistant: LYMPH: No history of systemic allergy, abnormal lymph nodes or swelling.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you have anyone with psychiatric symptoms in the family?
Patient: No, I don't have family!
Doctor: What do you mean?
Patient: My mom dad died and I was raised in the Philippines.
Doctor: Adopted?
Patient: No by myself.
Doctor: Wow that must have been tough.
Patient: Oh it's a story for another day.

assistant: Listed as unknown in the chart as far as other psychiatric illnesses. The patient himself states that his parents are deceased and that he raised himself in the Philippines.
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 chronic conditions I should know about, sir?
Patient: No, not that I can think of.
Doctor: What about injuries, have you ever broken a bone?
Patient: Yes, I have. I've broken my hand and tibia before.

assistant: The patient has no significant past medical history with the exception of previous hand fracture and tibia fracture.
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 to the clinic.
Patient: Thank you.
Doctor: Do you have any family history of cancer? Either solid tumors or blood malignancies?
Patient: No. None that I know of.

assistant: There is no history of solid tumor or hematologic malignancies 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: PASTSURGICAL

Dialogue:
Doctor: Can you tell me what surgeries have you had in the past?
Patient: I have had appendix surgery when I was twenty one years old and eight years back I had C Section.
Doctor: Okay. I want to know how many pregnancies you had and how many babies?
Patient: Sure, I have only two.
Doctor: Okay. Do you have any issues with your periods?
Patient: Yes, I get heavy periods because of fibroids in my uterus.
Doctor: Oh. When was your last menstrual period?
Patient: Oh, you can say about three weeks back.
Doctor: Okay. Good.

assistant: Appendectomy at age 21. C-Section 8 years ago. Ob/Gyn: G2P2; last menstrual period 3 weeks ago. Heavy menses due to fibroids.
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. Before we begin your visit, could you verify your age and ethnicity for me, please?
Patient: I'm forty nine years old, and I identify as white.
Doctor: Thank you. What brought you in today?
Patient: I was referred to you so that I could get whatever's wrong with me under control.
Doctor: I see. What seems to be happening?
Patient: I hurt the back of my leg pretty bad this past year when I was in A B C D.
Doctor: What part of your leg?
Patient: The back of my left thigh.
Doctor: I see. So just the leg?
Patient: I also hurt my kneecap from a boat when I was out in the water fishing.
Doctor: Was that severe?
Patient: It was a whole show. A helicopter came down and swooped me to X Y Z Hospital, where I got surgery.
Doctor: I can see you still have an external fixation on your knee so that the fracture heals. Did the hospital give you a report on the surgery?
Patient: Yeah, they did. Here you go.
Doctor: Thank you. Let me take a look. So, it looks like you underwent grafting and full thickness skin grafting for closure for a large defect in your left posterior thigh. That seems to be healed in the gluteal fold on the left area.
Patient: Yeah. Whatever that means.
Doctor: Let me examine the area.
Patient: Go for it.
Doctor: I can see several areas that have hypergranulation tissues around the graft site and low in the leg.
Patient: Is that bad?
Doctor: I don't think so. Are you feeling any symptoms of a fever or anything?
Patient: No, I'm not.
Doctor: That's good. You don't have any infections then.

assistant: This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted actually up to XYZ Hospital and underwent extensive surgery. He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area. In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue. He has some drainage from these areas. There are no signs and symptoms of infection. He is referred to us to help him get those areas under control.
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: And are you working?
Patient: Ah yes, I am a painter.
Doctor: Okay good.
Doctor: Do you smoke?
Patient: Yes, I do.
Doctor: Hm and how much do you smoke?
Patient: Well, about two packs a day.
Doctor: And how about alcohol, do you drink?
Patient: No sir, I don't drink.
Doctor: Any drugs?
Patient: You mean like cocaine and stuff?
Doctor: Yeah.
Patient: No, no drugs.

assistant: He does smoke two packs of cigarettes per day. He has no alcohol or drug use. He is a painter.
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 the clinic, ma'am. I am Doctor Smith.
Patient: Thank you. It is nice to meet you.
Doctor: Doctor X referred you to us, is that correct?
Patient: Yes. He is my primary care doctor.
Doctor: It looks like you have a birthday coming up. Happy early birthday!
Patient: Thank you. Yes, I am going to be seventy seven.
Doctor: Doctor Kim's notes said that you have had pain in the left flank pain. Can you tell me more about the pain?
Patient: Yes. The pain started four or five days ago. It has been in my stomach and through to my back, on the left side. Right here.
Doctor: Okay. Have you had any nausea or vomiting?
Patient: Yes. I had some nausea, and I threw up a few times.
Doctor: Have you noticed any blood, pain and or burning during urination?
Patient: No.
Doctor: Any fever or chills?
Patient: No.
Doctor: I have the ultrasound results that Doctor X ordered the other day. The ultrasound found a stone in your left ureteral. The stone is about one point three C M in size.
Patient: Is there some thing we can do to remove it? I really want this taken care of.
Doctor: Yes. Let us go over the treatment options.

assistant: The patient is a 76-year-old female who was referred to us from Dr. X for left flank pain. The patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient's history. The patient has had pain in the abdomen and across the back for the last four to five days. The patient has some nausea and vomiting. The patient wants something done for the stone. The patient denies any hematuria, dysuria, burning or pain. The patient denies any fevers.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Good afternoon, ma'am. You're forty one years old, correct?
Patient: Good afternoon, doctor. Yes, that's correct.
Doctor: Thank you, have you followed up with Doctor X since your surgery?
Patient: Why would I do that?
Doctor: Oh, just because she referred you to me.
Patient: Oh, no, I haven't yet.
Doctor: That's fine. Have you heard the details behind your surgery?
Patient: I heard it once, but I can't remember anything. Can you remind me?
Doctor: Well, you had a complicated case, but we did an anterior cervical discectomy, two level corpectomy, with a spinal decompression and fusion with fibular strut and machine allograft in your large cervical plate.
Patient: Oh, that's a lot, doctor.
Doctor: Yes, how are you doing today?
Patient: Well, I've felt good for the last two days.
Doctor: Have you been able to move your arms and legs for the last few days?
Patient: Yeah, I can actually move all four.
Doctor: Good, are you having any issues breathing?
Patient: No, nothing of note there.
Doctor: Okay, today, I think you'd be a good candidate for a halo vest placement.
Patient: Yeah, doctor, I'm not going back to the O R.
Doctor: Okay, we can do it here.
Patient: Okay doctor, I'd like to do it here.
Doctor: Let me get A B C to help me with this. Also, we're going to move you to S I C U room one.
Patient: Can you tell me the details about what you're going to do?
Doctor: Well, this is a P M T halo, I like this one better than the Bremer halo vest, and I'll use morphine and Versed.
Patient: Are you going to use anesthesia?
Doctor: Yes, I have local anesthetic, it's xylocaine and epinephrine, um, it's somewhere between fifteen and twenty C C.

assistant: The patient is a 41-year-old female who presented to me with severe cervical spondylosis and myelopathy. She was referred to me by Dr. X. The patient underwent a complicated anterior cervical discectomy, 2-level corpectomy, spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate. Surgery had gone well, and the patient has done well in the last 2 days. She is neurologically improved and is moving all four extremities. No airway issues. It was felt that the patient was now a candidate for a halo vest placement given that chance of going to the OR were much smaller. She was consented for the procedure, and I sought the help of ABC and felt that a PMT halo would be preferable to a Bremer halo vest. The patient had this procedure done at the bedside, in the SICU room #1. I used a combination of some morphine 1 mg and Versed 2 mg for this procedure. I also used local anesthetic, with 1% Xylocaine and epinephrine a total of 15 to 20 cc.
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: Is everything fine?
Guest_family: My mom is not well.
Doctor: When did this start?
Guest_family: I don't know but she is not in her correct state of mind.
Doctor: Okay let's see what we can do, how old is she?
Guest_family: She is around seventy four years old.
Doctor: Okay. Don't worry, we will see what we can do.
Guest_family: Thanks!
Doctor: Of Course.

assistant: A 74-year-old female patient admitted here with altered mental status.
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 in, sir.
Patient: Thank you.
Doctor: Let us start off with a little background.
Patient: Okay.
Doctor: What is your current living status? Do you live with others or on your own?
Patient: Well, right now I am living with my sister in Sacaton. I am currently looking for my own place, but I am staying with her for now.
Doctor: Are you looking for a place in Sacaton?
Patient: No. I will probably look for a place back in Coolidge.
Doctor: Back in Coolidge? Have you lived there before?
Patient: I recently separated from my wife. We lived in Coolidge together. Sacaton is too far away from everything, but it is fine for now.
Doctor: I am so sorry to hear that.
Patient: Thank you. My sister has been a saint. I am not working right now so my sister is letting me stay with her for free. She gave up her home office and made me a nice room to stay in.
Doctor: Your sister is very generous. Are you and your sister close?
Patient: Not when we were growing up but now that we are older, we have become very close. She has been a great support for me in these hard times.
Doctor: That's wonderful. Are you a tobacco user?
Patient: I smoke cigarettes. I only smoke a little bit.
Doctor: How much do you smoke per day?
Patient: I only smoke about one or two cigarettes a day.
Doctor: Do you or have you ever used drugs or alcohol?
Patient: I have never used drugs. I used to be a heavy drinker. I quit drinking a year ago.
Doctor: That's great. Do you attend A A meetings?
Patient: No, but I might start. Things have been very stressful lately with the separation and being on unemployment.
Doctor: I think it could be beneficial to you.
Patient: Okay.
Doctor: I have a list for different support groups in the area that I can give you.
Patient: Great. Thank you.

assistant: He lives in Sacaton with his sister. He is separated from his wife who lives in Coolidge. He smokes one or two cigarettes a day. Denies drug abuse. He used to be a heavy drinker, quit alcohol one year ago and does not work currently.
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: EDCOURSE

Dialogue:
Doctor: How are you feeling after that insulin drip, Miss A B C?
Patient: I am feeling much better. My sugar levels are normal.
Doctor: Yes, between one hundred fifteen and one thirty four. So, on the second day after your admission they did laparoscopic removal of your gallstones. You were very difficult to intubate. But everything went well with surgery. There was some swelling and adhesions around your gallbladder, but all is well that ends well.
Patient: What was my blood sugar during surgery?
Doctor: Great question. After surgery they were around two thirty three.
Patient: I am getting a special insulin?
Doctor: Yes, sliding scale insulin.
Patient: Can I go home?
Doctor: Yes, you are all set to go home, everything is stable.

assistant: Ms. ABC was admitted to the hospital. She was seen by Dr. A. He put her on an insulin drip. Her sugars slowly did come down to normal down to between 115 and 134. On the next day, she was then taken to the operating room, where she underwent her laparoscopic cholecystectomy. She was noted to be a difficult intubation for the procedure. There were some indications of chronic cholecystitis, a little bit of edema, mild edema and adhesions of omentum around the gallbladder. She underwent the procedure. She tolerated without difficulty. She was recovered in the Postoperative Care Unit and then returned to the floor. Her blood sugar postprocedure was noted to be 233. She was started back on a sliding scale insulin. She continued to do well and was felt to be stable for discharge following the procedure.
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: Welcome to A B C D General Hospital. My nurse says that you are forty one years old, and you identify as a White female, is that correct?
Patient: Yes, that's all correct.
Doctor: Thank you, so, what seems to be the trouble today?
Patient: Well, I'm having some pain in this foot, it's right over this bone.
Doctor: Is your pain right here?
Patient: Yes, it really hurts right there.
Doctor: Okay, this is known as your navicular bone. What makes the pain worse?
Patient: Usually wearing shoes makes it worse.
Doctor: Do you have any past history of problems with this foot?
Patient: Well, I have a history of multiple osteochondromas.
Doctor: Do they know what caused these?
Patient: No, no one ever figured it out, they just said it was hereditary.
Doctor: Have they done surgery on these in the past?
Patient: Yeah, I had a surgery for this a while ago.
Doctor: Have you ever had this problem in your feet or spine?
Patient: No, this is new. Can we do that surgery again? I can't take this pain.

assistant: This 41-year-old Caucasian female who presents to ABCD General Hospital. The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin. She states that she has been diagnosed with hereditary osteochondromas. She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back. The patient desires surgical treatment at this time.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTSURGICAL

Dialogue:
Doctor: On April twenty two four we went over your list of medication and allergies.
Patient: Okay.
Doctor: Let me check something.
Patient: Sure.

assistant: As listed on 04/22/04 along with allergies 04/22/04.
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: How's the low fat and low cholesterol diet going? Have you been finding it manageable?
Patient: Yeah, I guess. I've tried to also reduce my salt intake to about two grams.

assistant: 2 g sodium, low fat, low cholesterol diet.
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. Before we begin your visit, could I ask a few questions to fill in some missing information?
Patient: Yeah, that's fine.
Doctor: Does your family have any health related problems?
Patient: Yeah, we do. We have a strong history of heart disease. I think it could be because we drink a lot.
Doctor: So, would you say alcoholism runs in your family?
Patient: Oh, yeah. We drink a lot every day. Beer, liquor, you name it.

assistant: Strong for heart disease and alcoholism.
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 working these days?
Patient: No, sir. I've been retired for a couple years now.
Doctor: Congratulations. I hope you're enjoying your time off.
Patient: You bet.
Doctor: You mentioned having a smoking history. When did you quit and approximately how much did you smoke?
Patient: Uh I quit about twenty seven years ago. If I had to guess, I smoked about two packs a day.
Doctor: Did you smoke only cigarettes?
Patient: Cigars, too.
Doctor: How about alcohol?
Patient: Hardly ever.
Doctor: Great.

assistant: The patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars. He has not smoked for the past 27 years. He hardly ever uses alcohol. He is currently 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 morning, sir, welcome to A B C D General Hospital.
Patient: Thank you, doctor. I hope you can fix me up quickly.
Doctor: We'll do our best. Um, before we begin, I just need some background information. So, how old are you?
Patient: I'm forty seven years old.
Doctor: Good, and what race do you identify with?
Patient: I identify as white, sir.
Doctor: Thank you, so, what seems to be the problem today?
Patient: Well, I have this, um, mass of my left foot, it's been getting worse too.
Doctor: I see it. How long has this tissue mass been there on that foot?
Patient: It's been about two weeks now, but it's getting worse way faster now.
Doctor: Do you have any history of cancer?
Patient: No, but I've had an, um, shave biopsy in the past.
Doctor: I see.
Patient: Is there any surgery we can do for this to cut it off? I really want it gone.

assistant: This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot. The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size. The patient also has history of shave biopsy in the past. The patient does state that he desires surgical excision at this time.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: What do you do for a living?
Patient: Actually, I'm retired now, but I was an engineer, and I did some real estate brokering as well on the side.
Doctor: Wow, that's a lot. Congratulations on your retirement!
Patient: Thank you, now I get to spend more time with my wife.
Doctor: Wonderful, do you have any children?
Patient: Yes, five in total, it's a full house.
Doctor: Fantastic, do you drink or smoke?
Patient: I don't smoke, but I drink a little.
Doctor: How many drinks would you say you have a week?
Patient: Um, I'd say up to three drinks a week.
Doctor: Okay, and is there any history of drug or illicit substance abuse, sir?
Patient: No, never anything like that.

assistant: The patient is married with five children and lives with his wife. He is a retired engineer and real estate broker. He denies tobacco use. He drinks alcohol occasionally with up to three drinks a week. No history of drug abuse.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: DIAGNOSIS

Dialogue:
Doctor: As per your chart I am going to put some of the following things in your diagnosis.
Patient: Yes, I have diabetes, hypertension and gallstones.
Doctor: Yes I can see that in your chart over here.
Patient: What are the new things?
Doctor: We now have added hyperglycemia and obstructive sleep apnea.

assistant: Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you have any orthopedic conditions that run in your family that I should know about?
Patient: What, like arthritis?
Doctor: Yeah, does anything like that sound familiar?
Patient: No, not that I know of.

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: PASTMEDICALHX

Dialogue:
Guest_clinician: Hi there! Welcome to the clinic.
Patient: Hi! Thank you.
Guest_clinician: I'm going to get a little background information from you today.
Patient: Okay.
Guest_clinician: What are any of your medical history conditions? Past and present?
Patient: I have Crohn's disease.
Guest_clinician: How long have you had Crohn's?
Patient: Oh, I don't know. A long time twenty five to thirty years.
Guest_clinician: Have you had a colonoscopy recently?
Patient: I had one, four years ago. Do I need to get another one this year?
Guest_clinician: I am not sure. I will ask the doctor what his recommendation is for you would be. I will let him know that you had a colonoscopy four years ago.
Patient: Sounds good. I am also a diabetic. That has been going on for four years now.
Guest_clinician: Yes, I see you take insulin. I also see that you're on a blood pressure medication, do you have high blood pressure?
Patient: Yes, I have high blood pressure and high cholesterol. I also have heart disease. I had a stent placed in there.
Guest_clinician: Anything else?
Patient: I have arthritis now. They said it's due to my Crohn's.
Guest_clinician: That makes sense.
Patient: I'm being treated for depression now as well.
Guest_clinician: Okay. Any other surgeries other than the stent?
Patient: Oh, I had a kidney stone removed several years ago. Twenty five years ago. That's it. That's all I got for you.
Guest_clinician: Okay, great! Thank you. I will go let the doctor know that you are ready and she will be right in to see you.
Patient: I'll be here.

assistant: He has had diabetes for five years. He also has had hypercholesterolemia. He has had Crohn's disease for 25 or 30 years. He has had a colostomy for four years. He has arthritis, which is reportedly related to the Crohn's disease. He has hypertension and coronary artery disease and is status post stent placement. He has depression. He had a kidney stone removed about 25 years ago.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ROS

Dialogue:
Doctor: Any sugar or B P problem?
Patient: No, it is normal.
Doctor: Okay, how about thyroid or any other hormone related problem?
Patient: No, everything is fine.
Doctor: Cholesterol?
Patient: No cholesterol problem.

assistant: ENDOCRINE: Normal; Negative for diabetes, thyroid, or problems with cholesterol or hormones.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: DIAGNOSIS

Dialogue:
Guest_clinician: What's her diagnosis?
Doctor: Refractory anemia.
Guest_clinician: Gotcha.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you have patient's family history?
Guest_clinician: At this point of time, we don't have it.
Doctor: Hm, okay.

assistant: 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: Hello, miss. How can I help you today? The nurse said the matter was urgent.
Patient: Yes, I have been having dizzy spells. I have also noticed a new rash on my right calf.
Doctor: Can you describe what type of dizzy spells you are having? What do they feel like?
Patient: It is general dizziness and vertigo. I am also lightheaded during the spells.
Doctor: Are you feeling okay right now or are you experiencing symptoms?
Patient: I am having headaches off and on randomly, but nothing right now. The neck pain and muscle aches also are intermittent.
Doctor: Let me take a look at the rash on your legs. Are the bruises new?
Patient: They are new, I think. I have noticed them more than usual.
Doctor: In the past couple days have you had a fever or chills?
Patient: No, nothing like that.
Doctor: What about chest pains?
Patient: I have had some tightness in my chest, but not right now.
Doctor: Does the dizziness make you nauseous?
Patient: Yes, but I have not had to throw up or anything.
Doctor: What about diarrhea?
Patient: No, thank goodness.
Doctor: Are there any parts of your body that are hurting?
Patient: I do have some left shoulder pain. Not so much painful, but it is uncomfortable and tender.
Doctor: Have you measured your blood sugar at all? I ask because the notes state there is a history of gestational diabetes and when blood sugars are out of the normal limits this can cause some of the symptoms you are having.
Patient: I measured it today. After lunch it was one fifty five.

assistant: The patient is in complaining of headaches and dizzy spells, as well as a new little rash on the medial right calf. She describes her dizziness as both vertigo and lightheadedness. She does not have a headache at present but has some intermittent headaches, neck pains, and generalized myalgias. She has noticed a few more bruises on her legs. No fever or chills with slight cough. She has had more chest pains but not at present. She does have a little bit of nausea but no vomiting or diarrhea. She complains of some left shoulder tenderness and discomfort. She reports her blood sugar today after lunch was 155.
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: Does anyone in your family have or have history of any colon cancer or unusual polyps?
Patient: No.
Doctor: Any other family history?
Patient: Yes, my father died of a cancer called mesothelioma and my mother died of Hodgkin's Lymphoma.

assistant: Negative for any colon cancer or polyps. Her father died of mesothelioma, mother died of Hodgkin lymphoma.
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 known medical history in the family?
Patient: Nope.
Doctor: How about anyone with high blood pressure or heart disease or diabetes in the 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: GENHX

Dialogue:
Doctor: How are you feeling today?
Patient: I am feeling very tired.
Doctor: According to your chart, you have seen with us for three separate self harm attempts. Have you had any other self harm events that you have not come to see use for?
Patient: No. I have been seeing Doctor Lin.
Doctor: I also see that this is your third time in the last two months that you have attempted to harm yourself. Is there anything that is currently going on in your life that could be triggering these resent episode?
Patient: Last month I lost my job. And then this month my boyfriend left me.
Doctor: I am so sorry. That is a lot to deal with.
Patient: Yeah, it has been hard.
Doctor: Have you been diagnosed with any mental health conditions?
Patient: Doctor Lin just said that I was depressed.
Doctor: Have you ever been put on any medication for the for your depression?
Patient: I have taken Lexapro before.
Doctor: How long ago did you take the Lexapro?
Patient: I can't remember.
Doctor: Okay.

assistant: As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X. She has a remote history of being on Lexapro for depression.
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: So, if you see here Doctor Patrick there are multiple areas with hypergranulation tissue on the left leg posteriorly and I get a sense that it's associated with the trauma to the back of his right leg.
Guest_clinician: Yeah, I agree.

assistant: Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.
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: Okay, so your psych evaluation came out unremarkable. Do you have any other problems?
Patient: I have this acne. I hate it. I am not feeling comfortable in my own skin.

assistant: Acne. Psychiatric history is 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 there, how are you?
Guest_family: I am little scared.
Doctor: I understand, so how old is she?
Guest_family: She is ten days old today.
Doctor: And just wanted to confirm the ethnicity is Caucasian, right?
Guest_family: Yes.
Doctor: Okay, so tell me what's going on with her?
Guest_family: I was feeding her and then I suddenly noticed this unusual jerky movement in both her arms and legs.
Guest_family: It lasted about a minute.
Doctor: When did you first notice it?
Guest_family: The first day when I was feeding her, she was barely a day old.
Doctor: Okay, and how many times till now?
Guest_family: About six times.
Doctor: Did you notice any interrupted breathing or bluish color around her mouth?
Guest_family: No.
Doctor: While the episode occurs do you notice any color changes in the baby?
Guest_family: No.
Doctor: Did you happened to notice any arching of the back or eyes rolling back?
Guest_family: No, it usually happens while she is sleeping, so I didn't notice her eye movements. But I am able to wake her up and stop the hand and leg movements.
Doctor: Okay. Otherwise, is she feeding well and is active?
Guest_family: Yes, absolutely! Although she falls asleep a lot during breast feeding but other than that everything is fine.
Doctor: And how often are you feeding her and for how long?
Guest_family: I breast feed her every two to three hours for about fifteen to twenty minutes.
Doctor: Okay, and how many dirty diapers?
Guest_family: Well, her pee diapers have increased to up to eight and I would say about six to seven poopy diapers a day.
Doctor: And did you notice the color of her poop?
Guest_family: Yeah, it's like dirty yellowish color.
Doctor: Okay.

assistant: The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. Mom denies any apnea, perioral cyanosis, or color changes. These movements are without any back arching. They mainly occur during sleep, so mom is unaware of any eye rolling. Mom is able to wake the patient up during this periods and stop the patient's extremity movements. Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast. She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours. She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Has anyone in your family had heart diseases?
Patient: Yes my father. They did his heart bypass surgery when he was sixty.
Doctor: Is he alright now?
Patient: Yes I know what you mean.
Patient: Yes by God's grace, both my parents are alive.
Doctor: What exactly was the heart disease named? Do you know?
Patient: Yeah they said it was something called coronary artery disease and he had many strokes due to that.
Doctor: How old is he now?
Patient: My father is in his eighties. My mother is eighty years old too and she has dementia. My father has dementia too.
Doctor: Okay. Do you smoke or drink alcohol? And how much?
Patient: No I do not drink or smoke.

assistant: Strongly positive for heart disease in his father. He had a bypass at age 60. Both parents are alive. Both have dementia. His father has history of coronary artery disease and multiple vascular strokes. He is in his 80s. His mother is 80, also with dementia. The patient does not smoke or drink.
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: Are you on steroids?
Patient: No.
Doctor: Any history of cancer, chemotherapy or anything related?
Patient: No.

assistant: IMMUNOLOGIC: Negative; Negative for steroids, chemotherapy, or 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: DISPOSITION

Dialogue:
Doctor: How have you both been doing?
Guest_family: We are good.
Doctor: I see she has been gaining weight since she has been home. Have you been following the meal plan that we discussed?
Guest_family: Yes. It has been helping.
Doctor: Great!

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

user: Section: PASTMEDICALHX

Dialogue:
Guest_clinician: I don't see any past medical history here in this report.
Doctor: We don't have any record of P M H for this patient.
Guest_clinician: Okay.

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

user: Section: CC

Dialogue:
Doctor: Oh, dear God! What happened?
Guest_family: Hi Doctor, I am his mom.
Doctor: Hello, so what happened?
Guest_family: He was trying to climb a tree, slipped from there and got a deep cut on his thigh.
Doctor: So, you fell from the tree?
Patient: Yes.

assistant: Fall and laceration.