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: Hello. How are you both doing today?
Guest_family: We're doing great. The E D told us to come here. We're here to see if we could get the stuff in his leg taken out.
Doctor: I see. Did he have a fracture before?
Guest_family: Yeah, he did. Here's the report from the surgery from October two thousand and seven.
Doctor: Great. Let me take a look. It looks like he had a distracted left lateral condyle fracture. He then underwent screw compression to fix the fracture, correct?
Guest_family: That's correct.
Doctor: Perfect. So, now we just have to remove the hardware that was used to fix the fracture, right?
Guest_family: Yeah, that's correct. What are the risks of the surgery?
Doctor: The risks include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion.
Guest_family: Oh, wow. That's a lot. Could you go over the benefits?
Doctor: Of course. Before I do, I just need to confirm your son's age.
Guest_family: He can tell you.
Patient: Hi. I'm five years old. My birthday is in four months.
Doctor: Thank you. Happy almost birthday.
Guest_family: He gets excited about birthdays. I just have a few more questions, but it looks like we're going to go through with the surgery.

assistant: The patient is a 5-year, 8-month-old male who presented to me direct from ED with distracted left lateral condyle fracture. He underwent screw compression for the fracture in October 2007. The fracture has subsequently healed and the patient presents for hardware removal. The risks and benefits of surgery were discussed. The risks of surgery include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion. All questions were answered and the family agreed to the above plan.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: IMAGING

Dialogue:
Doctor: I am looking at her x ray report and she had a sternotomy in the past.
Guest_clinician: Yes, and we placed an I C D implant and an aortic valve mechanical implant. Her pleural effusion was really worrisome causing left sided opacification of her diaphragm.
Doctor: Oh I see!

assistant: Chest x-ray shows previous sternotomy with ICD implantation and aortic valve mechanical implant with left-sided opacification of the diaphragm worrisome for pleural effusion.
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 happened to your right leg?
Patient: I had a little accident with a dog, he bit me. I got really scared.
Doctor: Don't worry we will take care of this.

assistant: Dog bite to his right lower 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: GENHX

Dialogue:
Doctor: We've been following you for several conditions for a while now. What seems to be the problem today, sir?
Patient: Um, I was peeing blood, it's back again.
Doctor: Did you do anything that could have provoked it to come back?
Patient: No, not that I know of.
Doctor: Have you been taking the Flomax for your B P H?
Patient: Yes, I have been.
Doctor: What about the Coumadin?
Patient: Yes, I've been taking that too. It has been held recently, but I ususally take it.
Doctor: Remind me, I don't have my chart with me. What conditions have you been taking the Coumadin for?
Patient: I have A F I B and stroke.
Doctor: Thank you. Isn't this your second occurrence of gross hematuria this month?
Patient: Yes, doctor.
Doctor: Are you sure you haven't experienced any falls or anything recently?
Patient: Yeah, actually I fell about a week ago.
Doctor: Where is your pain from that fall?
Patient: It's in my butt and leg.
Doctor: Have you had your x rays taken yet?
Patient: Yeah, the x ray tech just brought me back.
Doctor: Okay, these x rays of the hips, knees, and ankles show severe degeneration in all areas.
Patient: What does that mean, doctor?
Doctor: I see some pretty significant arthritis in these areas.
Patient: Can you tell me some good news, please?
Doctor: Well, I don't see any fractures.
Patient: I guess that's something.
Doctor: When is your pain worst?
Patient: It's so severe, and it's worst first thing in the morning.
Doctor: Okay, I know you are, but be sure to keep taking the Coumadin, that helps with the stroke and A F I B.
Patient: Yeah, I will. I'm having problems with my sinuses today too. Can I get some nasal spray too?

assistant: I am following the patient today for multiple issues. He once again developed gross hematuria, which was unprovoked. His Coumadin has been held. The patient has known BPH and is on Flomax. He is being treated with Coumadin because of atrial fibrillation and stroke. This is the second time he has had significant gross hematuria this month. He also fell about a week ago and is complaining of buttock pain and leg pain. We did get x-rays of hips, knees, and ankles. Clearly, he has significant degenerative disease in all these areas. No fractures noted however. He felt that the pain is pretty severe and particularly worse in the morning. His sinuses are bothering him. He wonders about getting some nasal saline spray. We talked about Coumadin, stroke risk, etc. in the setting of atrial fibrillation.
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 morning.
Patient: Good morning, Doctor.
Doctor: Are you married?
Patient: No sir, I'm happily single.
Doctor: Good for you, what do you do for a living?
Patient: I'm actually not working right now, I go to college full time.
Doctor: Even better for you, so do you drink or smoke?
Patient: No, I don't.
Doctor: What about more illicit substances?
Patient: Absolutely not, nothing like that.
Doctor: Do you like to work out?
Patient: I play tennis and swim every week, I love it.
Doctor: That's very good, you're keeping very healthy.

assistant: The patient is single. She is a full-time student at University. Uses no tobacco, alcohol, or illicit drugs. She exercises weekly, mainly tennis and 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: Has anyone in your family suffered from dementia?
Patient: Not that I'm aware of.
Doctor: Is there any other medical history in your family? Any other medical issues?
Patient: My mom died of a stroke.
Doctor: How old was your mom when she died?
Patient: She was sixty two.

assistant: Negative for dementia. Her mother died of a stroke at the age of 62.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: When was the last time you had a cigarette?
Patient: Seventeen years back.
Doctor: Okay, and how much did you used to smoke?
Patient: About one pack per day. I smoked for forty four years.
Doctor: Okay, how about any I V drugs?
Patient: No I have not done that.

assistant: The patient quit smoking 17 years ago; prior to that had smoked one pack per day for 44 years. Denies any alcohol use. Denies any IV 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: What brings this little guy in today?
Guest_family: He's been complaining of a sore throat since last night. I noticed his eyes were really puffy before he went to bed and that's when I gave him some Benadryl. At that time, he also seemed nasally.
Doctor: Sorry to hear that. Did he have a fever?
Guest_family: When I took his temperature last night, it was one O one.
Doctor: And did you give him anything for the fever?
Guest_family: I was worried about giving him something on top of the Benadryl.
Doctor: I see. And how has he felt otherwise?
Guest_family: He appears more sluggish than usual. Fortunately, he's eating and drinking well.
Doctor: Has he been coughing at all?
Guest_family: No, but his voice has been a kind of raspy.
Doctor: Any shortness of breath?
Guest_family: Um no.
Doctor: How about any episodes of vomiting, diarrhea, or stomach pain?
Guest_family: No, I don't think so.

assistant: Mom brings patient in today because of sore throat starting last night. Eyes have been very puffy. He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday. He has had low-grade fever and just felt very run down, appearing very tired. He is still eating and drinking well, and his voice has been hoarse but no coughing. No shortness of breath, vomiting, diarrhea or abdominal pain.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Do you have any major medical conditions that I should know about, sir?
Patient: Maybe, I might. What exactly do you mean by that, doctor?
Doctor: Well, it's broad, but it could be anything from depression to high blood pressure, to cancer.
Patient: Okay, that's what I thought. I have high blood pressure.
Doctor: What about your mental health, is there anything of note there?
Patient: Um, yeah, I have anxiety, too.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are you a student?
Patient: Yes, I am. I go to the University.
Doctor: What are you majoring in? Or do you know yet?
Patient: Yes! I am studying biology.
Doctor: Excellent! Do you live in the dorms?
Patient: Yes.
Doctor: Are you from the area?
Patient: I am from Breckenridge. That is where my parents live.
Doctor: That is a beautiful place to be from. Do you use any tobacco, alcohol, or recreational drugs?
Patient: I have smoked weed with friends, off and on but not much. I have a few beers at the occasional dorm party.

assistant: The patient is a student at the University majoring in biology. He lives in a dorm there. His parents live in Breckenridge. He admits to having smoked marijuana off and on with friends and drinking beer off and on as well.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: CC

Dialogue:
Doctor: Hello Hello!
Patient: Hi there, how are you? I have a bad headache so can you please switch off the lights, it's too bright and uncomfortable.
Doctor: Sure thing. Let's see what is going on here. How about that?
Patient: Much better.

assistant: Headache.
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: Okay, let's talk about your family history.
Patient: Oh, I have very disturbing family history!
Doctor: Why do you say so?
Patient: Well, my mother passed away due to heart attack in her late sixties and my father had liver cancer and he passed away from that.
Doctor: Oh-
Patient: Oh, that is not all. My one son suffers from hypothyroidism and my daughter's two kids have cerebral palsy from being born prematurely.
Doctor: Oh, that is so unfortunate.
Patient: Yeah.

assistant: Positive for mother passing away in her late 60s from heart attack, father had liver cancer, and passed away from that. One of his children suffers from hypothyroidism, 2 grandchildren has cerebral palsy secondary to being prematurely born.
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:
Patient: Hey, man.
Doctor: Hey, how's it going? It's been a while.
Patient: Yeah, it's been a while that's for sure.
Doctor: So anything new I should know of?
Patient: Uh I had some stuff on my chest that I saw a dermatologist for.
Doctor: What type of stuff?
Patient: I think they were cysts.
Doctor: Any cause for concern?
Patient: Nah, the dermatologist said everything came back alright.
Doctor: Glad to hear that.
Patient: Me too. I'm actually here to see if you can write me up a P P D slip.
Doctor: Is this for a job?
Patient: Yeah, my last one was negative, but I need to get another one. Last one I did was in nineteen ninety four.

assistant: Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis. He had a recent PPD which was negative in August 1994.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ROS

Dialogue:
Doctor: Have you notied her behaving strangly in any way?
Guest_family: No. She is acting perfectly normal.
Doctor: Has she been gagging, coughing, vomiting or any other symptoms?
Guest_family: No. The only thing that I noticed is that she spilled the liquid all over her clothes, the ground and on her hands.
Doctor: Did you see her ingest any of the fluid?
Guest_family: No. We didn't see her put it in her mouth. I looked inside her mouth and didn't see anything.

assistant: The child has not been having any coughing, gagging, vomiting, or other symptoms. Acting perfectly normal. Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes. They did not witness that she ingested any, but did not see anything her mouth.
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: Any past medical problems I should know of?
Patient: No, ma'am. I am forty three and this is the first time I have had a major issue. It's only been this past month where I've felt weaker than usual. I'm much more tired and short of breath whenever I move around.
Doctor: Any recent weight loss?
Patient: Yeah, I actually lost about fifteen pounds in less than two or three months.
Doctor: How's your appetite? Any nausea, vomiting, diarrhea?
Patient: Appetite is pretty fine. No nausea, vomiting, or diarrhea.
Doctor: How about fever, chills, sweats, cough?
Patient: No, ma'am.
Doctor: And any chest pain with your shortness of breath?
Patient: No, ma'am.

assistant: This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month. The patient also reports a 15-pound weight loss. He denies fever, chills and sweats. He denies cough and diarrhea. He has mild anorexia.
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: Did you have a full term delivery?
Guest_family: No, he is premature born.
Doctor: Was he hospitalized?
Guest_family: Yes.
Doctor: Was he on any machine like the ones that help breathing?
Guest_family: No.
Doctor: Was he ever hospitalized afterwards?
Guest_family: No.
Doctor: Did he have any surgery?
Guest_family: No.

assistant: Baby was born premature and he required hospitalization, but was not on mechanical ventilation. He doesn't have any hospitalizations after the new born. No 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: ALLERGY

Dialogue:
Doctor: Do you have any allergies?
Patient: No I do not.
Doctor: Okay.
Patient: Okay.
Patient: Are you only asking for medical allergies?
Doctor: No, I want to know about all allergies.

assistant: There are no known allergies.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Anyone smokes in the house?
Guest_family: Yes, we do.
Doctor: Both of you?
Guest_family: Yes, but outside, not inside.
Doctor: Okay.
Guest_family: We are careful.

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

user: Section: CC

Dialogue:
Doctor: How're you feeling today?
Patient: Not great.
Doctor: I'm sorry, why is that?
Patient: I've had a headache all week along with neck and lower back pain.
Doctor: How would you describe the headache?
Patient: Throbbing pain.
Doctor: Is it constant?
Patient: It comes and goes for the most part.
Doctor: How would you rate it on a scale of ten with ten being the worst?
Patient: A seven or eight.
Doctor: Do you have a headache currently?
Patient: No, not right this second.
Doctor: Have you taken-
Patient: Anything for the pain?
Doctor: Yes.
Patient: I took some Ibuprofen, but it doesn't seem to be helping much.
Doctor: Any other symptoms associated with the headache, such as fever, chills, nausea, vomiting, blurred vision, or sensitivity to light?
Patient: No, not really. I don't feel like I have a cold or anything.
Doctor: Any recent injuries to the head?
Patient: No.
Doctor: And your neck and lower back pain, is this new?
Patient: Eh I can't say. It's been bothering me for some time now, but the pain feels a bit different.
Doctor: How so?
Patient: I don't really know. It's more pronounced.

assistant: Headache and pain in the neck and lower back.
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 other problems?
Patient: I do actually, I have back disc degeneration.
Doctor: Oh really?
Patient: Yeah.
Doctor: When were you diagnosed with it?
Patient: Maybe twenty ten?

assistant: Significant for degenerative disc disease in the back.
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 family history of disease?
Guest_family: To be honest, I'm not sure. Possibly? I'd have to check and get back to you.

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: PASTSURGICAL

Dialogue:
Doctor: Do you have any history of surgical procedures?
Patient: I remember having surgery as a child, but I don't know what the surgery was for. It was so long ago.

assistant: Years ago she had surgery that she does not recall.
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: Who all are there in your family?
Patient: Well, it's just me and my brother now. My mom passed away due to stroke at the age of seventy nine.
Patient: My father had a good life with no medical conditions. He passed away due to old age, he was ninety one.
Doctor: Wow! Any family history of heart disease or diabetes?
Patient: My other brother had prostate cancer but that's just it. No diabetes or heart issues.
Doctor: Okay.

assistant: Mother died at age 79 of a stroke. Father died at age 91 of old age. Her brother had prostate cancer. She has one brother living. No family history of heart disease or diabetes.
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: And are you allergic to any drugs?
Patient: Oh yes, I am allergic to what you call Cipro-
Doctor: Ciprofloxacin?
Patient: Yes! And also, Asprin but that coated one, what is called?
Doctor: Oh, you mean enteric coated Aspirin?
Patient: Yes, yes, that one!

assistant: Ciprofloxacin and Enteric coated aspirin
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, I am Doctor Chandler.
Patient: Hello Doctor.
Doctor: So, tell me what's going on?
Patient: I am having a headache.

assistant: Headache.
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:
Patient: In the past I have been treated for osteomyelitis of my right fifth toe with I V antibiotics therapy.
Doctor: Oh, how long back was that?
Patient: Ah, about five years back! I was treated for six weeks.
Doctor: Oh, Okay. You also have a history of diabetes mellitus?
Patient: That is correct.

assistant: Positive for: 1. Diabetes mellitus. 2. Osteomyelitis of the right fifth toe, which was treated with intravenous antibiotic therapy for 6 weeks about 5 years back.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Do you have any major medical conditions that I should know about?
Patient: Oh, yeah, I have a whole list of things going on, doctor.
Doctor: Like what, ma'am?
Patient: Well, I have high blood pressure, hypothyroidism, arthritis, and G E R D.
Doctor: I see, what about any mental health, or neurological diseases?
Patient: Um, I have an anxiety disorder, and I had migraines about thirty years ago.
Doctor: Thank you, I also see on my chart that you've had Morton's neuromas before, is that true?
Patient: Yeah, I have one on both feet.

assistant: Hypertension, hypothyroidism, degenerative joint disease, GERD, anxiety disorder, Morton neuroma of her feet bilaterally, and distant history of migraine headaches some 30 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: PASTMEDICALHX

Dialogue:
Doctor: I will ask you a few questions about your past medical history. Were you ever diagnosed with anything medically related?
Patient: No.
Doctor: Were you ever diagnosed with diabetes or any heart conditions?
Patient: No.
Doctor: Did you ever take medications for any long-term disease?
Patient: No.
Doctor: Did you ever have any surgery?
Patient: No.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: So, who is in your family?
Patient: Well, my mom, dad, and I have four brothers aged eighteen, sixteen, fourteen and twelve and I also have a younger sister. She is only three.
Doctor: Wow, and you all stay together?
Patient: Yes, and we also have two dogs and two cats.
Doctor: Okay. And everyone at home is doing fine?
Guest_family: No, not really. Everyone at home is sick with a cough, cold and runny nose, except-
Patient: Except for my mom!
Guest_family: Yeah, except for me thankfully.
Doctor: Hm, and did you travel anywhere recently, especially during the holiday season?
Patient: No, right mom?
Guest_family: Yeah, we didn't travel anywhere recently.
Doctor: Okay. Anybody in your house smokes?
Guest_family: No.
Doctor: No exposure to smoke, right?
Guest_family: No.

assistant: At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister. All the residents at home are sick currently with cold, cough, runny nose, except for mom. At home also live 2 dogs and 2 outside cats. Mom denies any recent travel history, especially during the recent holidays and no smoke exposures.
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: So, are you on any medication currently?
Patient: Yes, I am taking Atenolol and Mevacor.
Doctor: Hm, and no allergy to any medicine?
Patient: Not that I know of.

assistant: She is on atenolol and Mevacor. ALLERGIES: NO KNOWN DRUG ALLERGIES.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: So how long have you two been married?
Guest_family: We've been together for twenty seven years now.
Doctor: Oh wow, that's so wonderful to hear. How did you guys meet?
Guest_family: We actually met in high school. We dated for some time and then we took a break, but we ultimately got back together.
Doctor: Aw, high school sweethearts. I have a few more questions to ask.
Guest_family: Shoot.
Doctor: Any tobacco, hard drugs, or alcohol?
Guest_family: She doesn't do any of that.
Doctor: Great. And do you know of any medical problems that run on her side of the family?
Guest_family: Nothing major.
Doctor: I see.

assistant: Married x 27yrs. Husband denied Tobacco/ETOH/illicit drug use for her. Unremarkable FHx.
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: I would like to get a detailed history of your inperforated anus and the curvature of the penis. It is a genetic condition. And do you know if you had surgery soon after birth?
Patient: Yeah, my mother said that I had to have surgery after she gave birth to me.
Doctor: Do you know all the surgeries that you have had for this?
Patient: I don't know if I have all of them written down, but I do have most of them here.
Doctor: Oh, good you have a list.
Patient: Yeah. I was hospitalized in nineteen seventy for a U T I. That is when the problems started happening. It was a really bad infection.
Doctor: Okay.
Patient: In nineteen eighty eight I the tissue removed from the anus. There was a blockage. They also did an operation in the shaft of the penis too.
Doctor: I bet things improved after that surgery.
Patient: It did. I have here in January of nineteen ninety one I had a cystoscopy to remove a blockage.
Doctor: Um hum.
Patient: In two thousand and one I had a colonoscopy that was normal. Later that year I had a biopsy of my prostate.
Doctor: What did the biopsy show?
Patient: They said I had severe inflammation in the prostate. I was never told that cause of the inflammation.
Doctor: Okay. Any other surgeries for your condition?
Patient: Oh yeah. I had that same procedure done again when I was twenty seven and twenty eight. The same one that I had as a newborn. I had a third surgery when I was seventy with just a correction of the shaft area.
Doctor: Um hum. Any other surgeries unrelated to your condition?
Patient: Yeah. I have it written down here. In two thousand and one there was a left rotator cuff repair with acromioplasty and distal clavicle resection and in two thousand and three I had a left inguinal hernia repair with M E S H. That is what my notes say.
Doctor: Have you ever had any complications during any of your surgeries?
Patient: Yeah, I did. I have a blood clot that apparently went into my lungs. I was very scary.
Doctor: That is very scary.

assistant: Soon after birth for treatment of an inperforated anus and curvature of the penis. At the age of 70 had another penile operation. At the age of 27 and 28 he had repeat operations to correct this. He did have complications of deep vein thrombosis and pulmonary embolism with one of those operations. He has had procedures in the past for hypospadias, underwent an operation in 1988 to remove some tissue block in the anus. In January of 1991 underwent cystoscopy. He was hospitalized in 1970 for treatment of urinary tract infection. In 2001, left rotator cuff repair with acromioplasty and distal clavicle resection. In 2001, colonoscopy that was normal. In 2001, prostate biopsy that showed chronic prostatitis. In 2003, left inguinal hernia repair with MESH.
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: As per your chart, I see you have C O P D and hypertension.
Patient: Yes that is right.
Doctor: Okay.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you use any tobacco products?
Patient: No.
Doctor: Do you drink alcohol or use any recreational drugs?
Patient: No.
Doctor: Any history of needle drugs or prescription drug abuse?
Patient: No.

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

user: Section: ASSESSMENT

Dialogue:
Doctor: Hi!
Patient: Hello, how are you?
Doctor: I am good.
Patient: I think I am all well now.
Doctor: Yes, looking at your results I think your kidney failure is resolved too.

assistant: Acute renal failure, resolved.
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, young man?
Patient: I am twenty one.
Doctor: Are you right handed or left handed?
Patient: I am right handed.
Doctor: So, tell me what brings you here today?
Patient: Everything started on the fifth of November. Then after I saw the gradual increase in my symptoms. So it was all like numbness. I could not feel my legs. They felt numb all the time and there was no coordination between them, and it also affected my walk. All these symptoms were at their limit in just like a half day or more. It is continuing the same way since then. I also feel like somebody is putting pins and needles on my legs approximately halfway up the calf on both sides.
Doctor: You said that you felt decreased coordination or less coordination between your legs, right?
Patient: Yeah, that's right. It totally feels like I'm walking in space and don't know where to put my next step. I have no up and down spatial awareness.
Doctor: Do you have any issue with the bowel movements?
Patient: Nope.
Doctor: What about this weakness or the numbness anywhere else except your legs?
Patient: No, it's only in the legs.
Doctor: Did anything help you with those symptoms?
Patient: Well, sometimes, you see, hot showers made me feel better, but it is like only sometimes.
Doctor: Any recent flu like symptoms?
Patient: Nope.
Doctor: Did anyone in your family have anything like that or any other medical issues that was like going on in your family?
Patient: Nope.
Doctor: Did you have any surgery before?
Patient: Nope.
Doctor: What about any other major health issues in the past?
Patient: No, no medical issues.
Doctor: Are you taking any kind of medication for anything?
Patient: No medications.

assistant: 21 y/o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11/5/96. The symptoms became maximal over a 12-24 hour period and have not changed since. The symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally. He noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space. He denied bowel/bladder problems, or weakness or numbness elsewhere. Hot showers may improve his symptoms. He has suffered no recent flu-like illness. Past medical and family histories are unremarkable. He was on no 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: GENHX

Dialogue:
Doctor: What brings you in to the clinic today?
Patient: Well, I have had a progressive loss of my vision in my right eye. My eye doctor told me that I should come and see a neurologist. So here I am.
Doctor: Okay. How long has the vision loss been progressing for?
Patient: About two months. It seems like it has been progressing really fast. I have always had bad vision in my left eye. That started about two years ago.
Doctor: Can you still see out of you left eye?
Patient: No. I am considered blind in this eye now.
Doctor: Have you had any other symptoms associated with your vision loss?
Patient: No.
Doctor: Any headaches?
Patient: Nope.
Doctor: What is you dominate hand?
Patient: What do you mean?
Doctor: What hand do you write with or use dominantly?
Patient: Oh! I am right handed.
Doctor: And how old are you?
Patient: I am sixty two.
Doctor: Okay. I would like to run some test now.
Patient: Okay.

assistant: This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS, and is now blind in that eye. She denied any other symptomatology. Denied HA.
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 history of rheumatic fever as a child?
Patient: No.
Doctor: Any history of anything other then usual childhood illnesses?
Patient: No.

assistant: Negative for rheumatic fever. The patient has usual childhood illnesses.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: So, tell me a little bit more about your family history, please.
Patient: Sure, I know that my grandmother on my mom's side had pancreatic cancer, and my dad had prostate cancer.
Doctor: Besides cancer, are there any other conditions that you know run in your family?
Patient: Um, I know that my dad had heart disease, as well as diabetes.
Doctor: Thank you, this is good information to know.

assistant: His maternal grandmother had pancreatic cancer. Father had prostate cancer. There is heart disease in the father and diabetes in the father.
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?
Patient: I am a registered nurse.
Doctor: That's nice.
Doctor: And do you smoke or drink?
Patient: No sir.
Doctor: Any history of drug abuse or anything?
Patient: Absolutely not!
Doctor: Okay, good.

assistant: No history of any smoking, alcohol, or drug abuse. The patient is a registered nurse by profession.
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 doing?
Patient: I am doing well, thanks. Just trying to come to you more regularly to make sure my lungs and heart are okay.
Doctor: That's great. The previous notes said that you quit smoking. Are you still off?
Patient: Yes, I quit in nineteen ninety six. I come yearly to the doctor's office to make sure that the damage I did to my lungs is monitored.
Doctor: You have a great attitude. I appreciate when patient's take their health into their own hands. We can only do so much, but it is up to the patient to bring themselves in.
Patient: Yeah. I smoked for a long time and I know it was bad for me. It was just the norm back in the day.
Doctor: Do you drink at all?
Patient: I do. Only occasionally.

assistant: Quit smoking in 1996. He occasionally drinks alcoholic beverages.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Guest_family: Hello Doctor. I am from High Hope assisted living center. I am Mister Rath's assigned assistant.
Doctor: Right. What brings you here?
Guest_family: I got some of Mister Rath's food diary sheets here. He has already lost fifteen pounds in the last three months. We were just wondering if he needed to lose anymore.
Doctor: Let me have a look.

assistant: The patient is brought in by an assistant with some of his food diary sheets. They wonder if the patient needs to lose anymore weight.
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: Your condition and all your vital signs look stable to me right now. You must be very careful as your condition can get poor or it might improve as well.
Patient: Okay, so what do you recommend?
Doctor: Do you have any support system? Is there anyone at home to take care of you?
Patient: Yes, my son and his family lives with me. They are very caring.
Doctor: That is good. Do take care of yourself and let me know if your condition worsens.

assistant: Guarded.
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: Where do you work?
Patient: I'm a truck driver. It's a big construction company. I work for them.
Doctor: Do you smoke?
Patient: Yeah.
Doctor: Cigarette or something else?
Patient: I do Cigar.

assistant: Cigar smoker. Truck driver.
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 morning, ma'am. I just need a few pieces of information before we get started today.
Patient: Good morning, doctor. Absolutely, that's not a problem at all.
Doctor: Do you smoke or drink, ma'am?
Patient: I don't smoke, and I drink, um, I'd say on occasionally.
Doctor: What about harder drugs, do you use any of those?
Patient: No, I don't.
Doctor: Are you married?
Patient: Yes, to my wonderful husband.
Doctor: That's great, what do you two do for a living?
Patient: I'm a social worker, and my husband is a high school chemistry teacher.
Doctor: What great work both of you are doing. What kinds of people do you work with as a social worker?
Patient: I love it, I work with adult abuse and neglect issues.
Doctor: Yes, that's great. Do you have any children?
Patient: Yes, we have two sons.
Doctor: Do they live at home?
Patient: No, they're both grown and on their own now.

assistant: She has no tobacco use. Only occasional alcohol use. She has no illicit drug use. She has two grown children. She is married. She works as a social worker dealing with adult abuse and neglect issues. Her husband is a high school chemistry teacher.
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: Did both your parents have heart complications.
Patient: Unfortunately, yes. My mom passed from a heart attack at seventy three and my father at eighty.
Doctor: I'm so sorry to hear that.
Patient: I lost my brother as well. He passed away from a brain tumor when he was nine years old.
Doctor: I can't imagine how hard that must've been.
Patient: It was a dark time in our lives, but we survived it as a family.

assistant: Father died of MI, age 80. Mother died of MI, age73. Brother died of Brain tumor, age 9.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are you married?
Patient: Yes. I have been married for twenty two years.
Doctor: Are you working?
Patient: No. I am unemployed. I have not completed my collage degree yet. I have been in school for the last two years.
Doctor: Keep at it.

assistant: unemployed. 2 years of college education. Married 22 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: ROS

Dialogue:
Doctor: Any fever, chills or rigors?
Patient: No.
Doctor: Any blurring of vision or history of glaucoma or cataract?
Patient: No.
Doctor: Did you experience any shortness of breath?
Patient: No.
Doctor: Any stomach discomfort?
Patient: No.
Doctor: Did you observe blood in your stool or in vomit?
Patient: No, nothing like that.
Doctor: Okay, good. Did you notice any increase in your urine frequency or urgency?
Patient: No.
Doctor: Do you feel any muscle weakness or tiredness?
Patient: No, nothing of that sort.
Doctor: Any known history of arthritis?
Patient: Nope.
Doctor: And no fever due to any fungal infection or anything, right? Like valley fever?
Patient: No, nothing of that sort.
Doctor: Any history of pneumonia?
Patient: No.
Doctor: And I am looking at your chart, so no history of stroke, C V A, or any seizure disorder.
Patient: That's correct.
Doctor: No thyroid or hormone related problem?
Patient: No.
Doctor: And you do not have any blood disorders, right?
Patient: That is right.

assistant: CONSTITUTIONAL: No history of fever, rigors, or chills. HEENT: No history of cataract, blurring vision, or glaucoma. RESPIRATORY: Shortness of breath. No pneumonia or valley fever. GASTROINTESTINAL: No epigastric discomfort, hematemesis, or melena. UROLOGICAL: No frequency or urgency. MUSCULOSKELETAL: No arthritis or muscle weakness. CNS: No TIA. No CVA. No seizure disorder. ENDOCRINE: Nonsignificant. HEMATOLOGICAL: Nonsignificant.
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: Have you experienced any diarrhea?
Patient: Yes. I have been having diarrhea. When I think about it, it started happening around the same time that the mouth sores started. I didn't have any diarrhea today though.
Doctor: Have you experienced any episodes of nausea or vomiting?
Patient: No.
Doctor: Have you noticed any blood in your bowel movements?
Patient: No.
Doctor: Even though you have been taking the medications without any issue, for about ten years, the methotrexate may be the cause of the mouth sores and the inflammation in the small intestines. These are both common side effects from the use of methotrexate. I am not as familiar with NSAID's causing mouth sores. Aspirin use can cause gastrointestinal upset. I think the most likely cause of the sores is the methotrexate not the use of Aspirin.

assistant: Erosive stomatitis probably secondary to methotrexate even though the medication has been used for ten years without any problems. Methotrexate may produce an erosive stomatitis and enteritis after such a use. The patient also may have an enteritis that at this point may have become more quiescent as she notes that she did have some diarrhea about the time her mouth problem developed. She has had no diarrhea today, however. She has noted no blood in her stools and has had no episodes of nausea or vomiting. I am not as familiar with the NSAID causing an erosive stomatitis. I understand that it can cause gastrointestinal upset, but given the choice between the two, I would think the methotrexate is the most likely etiology for the stomatitis.
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 on insulin?
Patient: Yes.
Doctor: Are you on metformin as well?
Patient: Yes.
Doctor: How about glucotrol?
Patient: Yes I take that.
Doctor: Are you on lipitor?
Patient: Yes.

assistant: Insulin, metformin, Glucotrol, and Lipitor.