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: EDCOURSE

Dialogue:
Guest_clinician: What was he given in the E R?
Doctor: Epi one M G, zero point three M L subcutaneously along with fifty M G of Benadryl intramuscularly. In about fifteen to twenty minutes, he reported his itching had improved. The rash itself faded a little bit and he began to feel a lot more comfortable.

assistant: The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly. After about 15-20 minutes he states that itching started to feel better. The rash has started to fade a little bit and feeling a lot more comfortable.
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: Hello, how are you?
Patient: I am good, Doctor.
Doctor: So, what brings you here today?
Patient: Well, I have many medical issues and I see Doctor X for them, but I wanted a second opinion, so he referred me here.
Doctor: Yeah, he is a good man! Don't worry we will take care of you.
Patient: Thank you.
Doctor: So, let me start by getting your medical history.
Patient: Sure, I had skin cancer which was treated by removal of that part.
Doctor: Okay.
Patient: Other than that, I have anemia and an acid reflux problem. I also have history of C O P D.
Doctor: Alright.
Patient: I also suffer from sciatica which was caused mainly due to my arthritis.
Doctor: I see.

assistant: The patient has multiple medical problems, for which she is under the care of Dr. X. She has a history of chronic obstructive lung disease and a history of gastroesophageal reflux disease. There is a history of anemia and there is a history of sciatica, which has been caused by arthritis. The patient has had skin cancers, which have been treated with local excision.
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 back to Sample Clinic, Mister Sample.
Patient: Good afternoon, doctor.
Doctor: What seems to be the problem today, sir?
Patient: I'm having a lot of pain in my right heel.
Doctor: How long have you had this pain?
Patient: Um, it's been about two weeks now.
Doctor: When is the pain the worst?
Patient: Honestly, it starts with the first step first thing in the morning.
Doctor: Does it get worse throughout the day?
Patient: Yes, it gets worse all day with activities.
Doctor: What treatments have you had for this?
Patient: Well, nothing to date.
Doctor: Where is your heel pain?
Patient: It's on the right heel, then it's on the inside bottom part of the heel and into the inside of the heel.
Doctor: Do you have any change in your medical history since your last visit?
Patient: No, it's the same old same old.
Doctor: Do you have any flu like symptoms?
Patient: Like fever or chills?
Doctor: That, or vomiting or headaches.
Patient: Oh, no I don't have anything like that.
Doctor: What about chest pain or shortness of breath?
Patient: Thankfully, no nothing like that.

assistant: Mr. Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel. The patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day. The patient states that he is currently doing no treatment for it. He states that most of his pain is along medial tubercle of the right calcaneus and extends to the medial arch. The patient states that he has no change in the past medical history since his last visit and denies any fever, chills, vomiting, headache, chest, or shortness of breath.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: What is your family medical history?
Patient: My family has a high blood pressure. I have a family member that had colon cancer. My daughter has a twitch. They don't know what caused it?
Doctor: Okay.

assistant: HTN, Colon CA, and a daughter with unknown type of "dystonia."
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 Long, I see that you have been referred today by A B C, D O, for a reevaluation. Are you having issues with your hand eczema again?
Patient: Yes, it has been flaring.
Doctor: Can you confirm your age for the records please?
Patient: Sure, I'm twenty nine.
Doctor: If I'm not wrong, you are from Vietnam, right?
Patient: That's right.
Doctor: Are you married? Single or with a partner?
Patient: I'm single.
Doctor: Are you working somewhere?
Patient: No, currently I'm unemployed.
Doctor: Okay, since you are an established patient here in our dermatology department, let me just update all your information into the records.
Doctor: Okay according to my records we have last seen you here in our office on July thirteenth of two thousand and four.
Patient: Yeah, I think so.
Doctor: I have previously treated you with Aristocort cream and Cetaphil cream. I also ask you to increase your moisturizing cream and lotion and asked you to wash your hands in Cetaphil cleansing lotion.
Patient: I've been doing all that, but now it looks like my eczema is flaring. I have these cracks in my hands and they feel very dry.
Doctor: Have you been washing your hands with Cetaphil cleansing lotion?
Patient: No, I was using soap. The Cetaphil cleansing lotion was not working. I had a lot of pain and burning sensation whenever I tried to use that.
Doctor: It may be because of the fissures. I mean those cracks in your hands.
Patient: I have been wearing gloves as much as I can.
Doctor: Okay.

assistant: This is a 29-year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04. She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema. I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion. She comes in today for reevaluation because she is flaring. Her hands are very dry, they are cracked, she has been washing with soap. She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin. She has been wearing some gloves also apparently. The patient is single. She is unemployed.
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: Have you been applying Triamcinolone zero point one percent three times a day to your rash?
Patient: The one on my left wrist?
Doctor: Yes. And Bactroban ointment is also three times a day as needed for your bug bites.
Patient: Yep.
Doctor: Are you still using Nystatin on your lips once a day as needed?
Patient: Uh yeah. I've been using it much less now.
Doctor: So let's see, your other medications are the same as of July thirtieth O four with the exception of Klonopin?
Patient: Yeah, I mean I'm taking four M G in the morning and six M G at night instead of the six M G and eight M G that was recommended. I feel like I do better with the lower doses.

assistant: She is currently on her nystatin ointment to her lips q.i.d. p.r.n. She is still using a triamcinolone 0.1% cream t.i.d. to her left wrist rash and her Bactroban ointment t.i.d. p.r.n. to her bug bites on her legs. Her other meds remain as per the dictation of 07/30/2004 with the exception of her Klonopin dose being 4 mg in a.m. and 6 mg at h.s. instead of what the psychiatrist had recommended which should be 6 mg and 8 mg.
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: So, I am looking at your reports, you don't have anemia or any other blood disorders.
Patient: Well, that's a relief!
Doctor: Yeah.
Doctor: Let me check your lymph nodes. They are nonpalpable. I don't see any swollen glands or anything.
Patient: Great!

assistant: HEMATOLOGIC/LYMPHATIC:: Normal; Negative for anemia, swollen glands, or blood disorders.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Guest_family: Hi, how are you?
Doctor: I am well, how's the baby? I see that he is eight pounds and thirteen ounces, and he was born via…?
Guest_family: Yes, C section. Yeah, he is he has never been hospitalized. He was born a week early.
Doctor: Okay, I would like to ask you some questions about the pregnancy and other history.
Guest_family: Yes, sure go ahead.
Doctor: Great, have you had any infections during pregnancy like G B S or S T D infections?
Guest_family: No, I haven't, I only had thumb and toenail infections and we treated that with rubbing alcohol. We have a history of boils in the family, so I am not afraid of minor infections like this.
Doctor: Did you smoke during pregnancy?
Guest_family: Yes, I did, but stopped after five months.
Doctor: Sir, have you had any S T D while she was pregnant?
Guest_family_2: No, I was not diagnosed with anything unusual.
Doctor: Great, so looks like you were discharged in forty eight hours and no more hospital stays for you.
Guest_family: That is correct.

assistant: The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section. Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family). GBS status was negative. Mom smoked up to the last 5 months of the pregnancy. Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions. Mom and baby were both discharged out of the hospital last 48 hours. This patient has received no hospitalizations so far.
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, sir. I am Doctor Jones.
Patient: Thank you. It is nice to meet you.
Doctor: Do you use tobacco products?
Patient: Yes. I smoke cigarettes. I am working on quitting.
Doctor: I am glad you are attempting to quit. We have a lot of tools now to help with cravings. How much do you smoke per day now?
Patient: I smoke about a pack a day.
Doctor: Do you drink alcohol or use recreational drugs?
Patient: I drink but I don't do any drugs.
Doctor: How many alcoholic drinks do you consume per week?
Patient: I drink about four drinks per night. I used to drink a lot more than that. I have cut back on my drinking.
Doctor: Are you physically active? Do you exercise?
Patient: I was very athletic when I was growing up. Now I don't exercise on a regular basis.
Doctor: What do you do for employment?
Patient: I am a network engineer. I work for Shepherd Pratt.
Doctor: Are you married?
Patient: Yes. I have been married to my wife for five years now.
Doctor: Do you live at home with your wife and or is there anyone else living in your home?
Patient: No. Just me and the wife.

assistant: He lives with his wife. He works at Shepherd Pratt doing network engineering. He smokes a pack of cigarettes a day and is working on quitting. He drinks four alcoholic beverages per night. Prior to that, he drank significantly more. He denies illicit drug use. He was athletic growing up.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are you married?
Patient: I'm divorced.
Doctor: So, do you live alone? Or do you have kids?
Patient: I live with my girlfriend, and we have a kid together. I also have three other kids from my former wife.
Doctor: Do you smoke?
Patient: I used to smoke. But I, I've quit like fifteen years ago.
Doctor: What about alcohol?
Patient: Yeah, I drink beer. Around one to two beers a day.
Doctor: Are you working?
Patient: I'm retired right now, but I used to work in an iron company.

assistant: Divorced and lives with girlfriend. One child by current girlfriend. He has 3 children with former wife. Smoked more than 15 years ago. Drinks 1-2 beers/day. Former Iron worker.
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 studying?
Patient: Yes. I'm doing my major in computer science.
Doctor: Do you live alone?
Patient: No, I live in my family. Mainly my parents and my sisters.

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

user: Section: PASTSURGICAL

Dialogue:
Doctor: Have you ever had surgery before?
Patient: No, not that I know of.
Doctor: So, no gallbladder removal, or joint replacements?
Patient: Unless they did it while I was sleeping, but none that I can remember.

assistant: No previous 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: FAM/SOCHX

Dialogue:
Doctor: I remember you had mentioned that one of your family members had bone cancer. Are there any other medical problems that run in your family?
Patient: Sadly, yes. Stroke and dementia are the other two big ones.
Doctor: I'm sorry to hear that.

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

user: Section: ALLERGY

Dialogue:
Doctor: Are you allergic to any meds?
Patient: Me?
Doctor: Yes.
Patient: No, I am not.
Doctor: Are you sure?
Patient: Yes, I am damn sure.
Doctor: Okay great!

assistant: None known to 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: DIAGNOSIS

Dialogue:
Doctor: What's bringing her in today?
Guest_family: Oh, doctor. She hasn't been doing well at all.
Guest_family: I think she's actually gotten worse.
Doctor: I understand. I'm sorry to hear that she hasn't been feeling well. Let me see what we can do for her today.
Guest_family: I haven't taken her temperature since this morning. It was one hundred and three degrees when she woke up.
Doctor: What time did she wake up today?
Guest_family: Um, around eight I believe. She also suffers from apnea.
Doctor: It looks like she has an upper respiratory infection.
Guest_family: Is she going to get better?
Doctor: Yes, she should feel better once we start treating the infection. But I'm worried it may be pertussis.

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

user: Section: CC

Dialogue:
Doctor: And you've had recurring abscesses for the past two years, correct?
Patient: Unfortunately, yes.
Doctor: Where have they been located?
Patient: Um in the public area and my thighs.
Doctor: Have you ever needed to get an abscess drained?
Patient: Yeah. I've gotten about four I and D's.

assistant: Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 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: PASTMEDICALHX

Dialogue:
Doctor: How's your overall health?
Patient: Fine, I guess. I'm being treated for I B S by my G I. Last time I was in, they told me that my white blood cell levels aren't where they were supposed to be.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you have any family history of chronic illnesses that I should know about?
Patient: What do you mean by that?
Doctor: Well, it could be anything from depression, to arthritis, to cancer.
Patient: Oh yeah, my mom has arthritis.

assistant: Patient admits a family history of arthritis associated with 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: PLAN

Dialogue:
Doctor: How are you moving around? Are you able to perform your day to day activities?
Patient: Little bit, not so much.
Doctor: So just listen to your body and go around as much as you can.
Patient: Okay.
Doctor: Do not overstress yourself.
Patient: Okay I can do that.

assistant: As tolerated.
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: Remind me, how did he hurt himself?
Guest_family_1: He was riding quads on October tenth two thousand seven when he got thrown off.
Doctor: Yes, and we did O R I F on his fracture dislocation of the left elbow.
Guest_family_1: Yes, he also fractured the neck of his right glenoid, um, if I remember correctly.
Doctor: Which hand does he write with?
Guest_family_1: He writes with his right hand.
Doctor: Okay. That fracture appears to have healed very well; kids generally heal pretty well. How does it feel today?
Guest_family_1: Yes, he's only ten. He's been pretty stiff, so he's been going to P T, and using his Dynasplint.
Doctor: That's good that he is already in P T. His left elbow fracture is healed, so we should do another surgery in order to remove that hardware. That may help decrease some of the irritation with elbow extension. He looks neurologically intact in terms of movement and reflexed in his wrist and hand.
Guest_family_1: Yes, I agree. What is the risk of infection of this surgery?
Doctor: Historically, the risk of infection is less than one percent.
Guest_family_1: Oh, wow, that's low, how is that possible?
Doctor: We'll use prophylactic antibiotics, this controls for infection, and helps keep everything clean. Other Risks include bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, and continued postoperative stiffness.
Guest_family_1: Wow, that's great, will be he asleep the entire time?
Doctor: Yes, we'll use anesthesia, he won't feel a thing.
Guest_family_1: Will this fix his pain, for sure?
Doctor: I can't guarantee it, he may still be in some pain.
Guest_family_1: Okay, what about you, dear? What do you think?
Guest_family_2: Yeah, I think we should do it, boys should be playing sports with their friends.

assistant: The patient is a 10-year-old right-hand dominant male, who threw himself off a quad on 10/10/2007. The patient underwent open reduction and internal fixation of his left elbow fracture dislocation. The patient also sustained a nondisplaced right glenoid neck fracture. The patient's fracture has healed without incident, although he had significant postoperative stiffness for which he is undergoing physical therapy, as well as use of a Dynasplint. The patient is neurologically intact distally. Given the fact that his fracture has healed, surgery was recommended for hardware removal to decrease his irritation with elbow extension from the hardware. Risks and benefits of the surgery were discussed. The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, continued postoperative stiffness. All questions were answered and the parents agreed to the above plan.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Since you have a family history of coronary heart disease, let me check you for its risk factors.
Patient: Yeah, my father had it.
Doctor: Any history of high blood pressure or diabetes?
Patient: No.
Doctor: How about smoking, do you smoke?
Patient: No, I don't smoke.
Doctor: And in the past, did any other Doctor mention that you might have sign or symptom indicating that you may have coronary artery disease?
Patient: No.
Doctor: Okay.

assistant: CORONARY RISK FACTORS: No history of hypertension or diabetes mellitus. Active smoker. Cholesterol status, borderline elevated. No history of established coronary artery disease. Family history positive.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Who all are there in your family?
Guest_family: It's me, my husband, my two older kids and this little baby.
Doctor: Everyone living together?
Guest_family: Yes
Doctor: Is she going to any daycare?
Guest_family: No, she's at home all the time.

assistant: Currently lives with her mom, dad, and two siblings. She is at home full time and does not attend day care.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you drink?
Patient: Oh, I do but occasionally. Who doesn't like a nice cocktail!
Doctor: Okay. How about cigarettes, do you smoke?
Patient: No, I don't smoke.

assistant: The patient does not smoke. She does have an occasional alcoholic beverage.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: CC

Dialogue:
Doctor: I am okay.
Patient: I have bad nausea.
Doctor: Oh, so sorry.
Patient: And I feel very dizzy like I am going to faint.
Doctor: Okay let me see what is going on.
Patient: Okay.

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

user: Section: CC

Dialogue:
Doctor: What brings you into the office today?
Patient: I had a stroke about a month ago. The right side of my face is still not moving.
Doctor: Is it only the right side of the face that is affected by paralysis?
Patient: Yes. It has improved a little bit since I was in the hospital.
Doctor: That is a good sign. It can take up to six months see how much movement you will regain.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you use tobacco?
Patient: What, like smoke cigarettes?
Doctor: Yes ma'am, do you?
Patient: Oh, no. I don't do anything like that.

assistant: She is a nonsmoker.
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: Have you ever had surgery, ma'am?
Patient: Yes, I had it for melanoma some time ago.
Doctor: I see here that you had a hysterectomy as well, is that correct?
Patient: Oh, yes, that's true. I had that done too.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: So, let's see here. You don't recall anyone in your family having a history of neuromuscular diseases, correct?
Patient: No, no one I can think of.
Doctor: Do you know of anyone who has had foot deformities or neuropathy in their arms or legs?
Patient: No, not one person comes to mind.
Doctor: Great. Does anyone in your immediate family have a high arch?
Patient: No, at least no one that I know of.
Doctor: And you said that your aunt or sister has type two diabetes?
Patient: My aunt. She's had it for some time now.

assistant: There is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases. His aunt has a history of type II 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: ASSESSMENT

Dialogue:
Doctor: So, what I feel is you might have short term memory loss due to high stress, but I also feel it's probably due to your current situation. The other impression I have is that you have anxiety issues and again it's stress related.
Patient: Yeah, I do have anxiety issues.

assistant: 1. Short-term memory loss, probable situational. 2. Anxiety stress issues.
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: Who's my patient today?
Guest_family: Today, it's my brother.
Doctor: What seems to be the problem today?
Guest_family: Well, he's a vegetarian but he has high cholesterol and he's on a medication to control it.
Doctor: Has he changed his diet?
Guest_family: Yes, he did when he got a letter saying that his fat levels were high in the blood.
Doctor: What kinds of foods did he eliminate?
Patient: Oh, you know, all of the fun ones. Like cappuccino, quiche, crescents, candy, vending machines, all of that stuff.
Doctor: Do you take your lunch to work?
Patient: Yes, I do about three or four times a week instead of eating out so much.
Doctor: Are you exercising right now?
Patient: Yes, I do about six or seven days a week.
Doctor: What kind do you like to do?
Patient: Well, I do just about everything. I swim, I bike, run and then I lift weights.
Doctor: How long do you workout per day?
Patient: Usually, it's about one and a half to two and a half hours every day.
Doctor: Good, are you training for anything specific?
Patient: Actually, yes I'm going to do a triathlon.
Doctor: Can I assume you're losing weight?
Patient: Yes, I am.

assistant: His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it. The patient started improving his diet when he received the letter explaining his lipids are elevated. He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc. He has started packing his lunch three to four times per week instead of eating out so much. He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time. He is in training for a triathlon. He says he is already losing weight due to his efforts.
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: The patient has possible free air in their diaphragm.
Guest_clinician: How old is the patient?
Doctor: Seventy six.
Guest_clinician: Past medical history?
Doctor: Unknown as of now.

assistant: Possible free air under the diaphragm.
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: Out of ten, ten being the worst pain imaginable, how would you rate your pain today?
Patient: Today it's about a six or seven, and it's usually pretty constant there.
Doctor: Does the pain change with the weather?
Patient: Yes, when it's cold out it turns to ten out of ten. It's better when it's warm out.
Doctor: Does the pain change throughout the course of the day?
Patient: Yes, it progressively gets worse and worse as the day goes on, but I also have a pretty hard time getting out of bed in the morning, too.
Doctor: Out of ten, how would you rate your pain at night?
Patient: Oh, it's ten out of ten.
Doctor: Does the pain wake you up at night?
Patient: If I sleep at all. I'm not sleeping well at all, and when I do it's for less than an hour at a time.
Doctor: Are there any activities that really aggravate the pain?
Patient: Yes, if I sit for more than about twenty minutes, or if I lay flat on my back.
Doctor: Does anything alleviate the pain?
Patient: Laying on my side helps a little.

assistant: The patient states that pain is constant in nature with a baseline of 6-7/10 with pain increasing to 10/10 during the night or in cold weather. The patient states that pain is dramatically less, when the weather is warmer. The patient also states that pain worsens as the day progresses, in that she also hard time getting out of bed in the morning. The patient states that she does not sleep at night well and sleeps less than one hour at a time. Aggravating factors include, sitting for periods greater than 20 minutes or lying supine on her back. Easing factors include side lying position in she attempts to sleep.
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:
Guest_family: For as long as I have been taking care of her, she has had this tracheal tube and she barely speaks. She mostly signals if she needs anything.
Doctor: Okay. It's mentioned in her report that she has a history of smoking.
Guest_family: She is nodding yes.
Doctor: Well, it's alright. I think it's going to be difficult taking any past medical information from her.

assistant: The patient had been previously a smoker. No other could be obtained because of tracheostomy presently.
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: Have you been taking anything for high blood pressure?
Patient: Yeah, I started taking Toprol and uh the one that starts with an A. I forget what it's called.
Doctor: Hm are you talking about Avalide?
Patient: Oh right, yeah that's the one.

assistant: Currently taking Toprol and Avalide for hypertension and anxiety as I mentioned.
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. Before we begin, may I ask how old you are?
Patient: Good afternoon, doctor. I'm fifty six years old, now.
Doctor: Great, thank you. What seems to be the problem today, ma'am?
Patient: Well, I need some support for dietary recommendations for healthy eating for my husband and me.
Doctor: Why would that be, ma'am?
Patient: Um, I have a lot going on, high cholesterol, high blood pressure, acid reflux, and I just want to lose some weight. My husband has high cholesterol too.
Doctor: Tell me more about your eating habits, please.
Patient: Well, we live by ourselves now that our children are gone, but I'm used to cooking really large portions.
Doctor: Are you struggling to make food for just two people?
Patient: Yes, that's a good way to put it. I'd like to just make less food, that way we're not so tempted to eat so much.
Doctor: I understand, are you busy, do you work?
Patient: Well, I start a new job this week.

assistant: This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. The patient states that her husband has been diagnosed with high blood cholesterol as well. She wants some support with some dietary recommendations to assist both of them in healthier eating. The two of them live alone now, and she is used to cooking for large portions. She is having a hard time adjusting to preparing food for the two of them. She would like to do less food preparation, in fact. She is starting a new job this week.
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! What brings you into the office today?
Patient: Hi! I have not been able to go pee, and I have had this sharp pain in my left side.
Doctor: Have you recently had any surgical procedures?
Patient: No.
Doctor: Do you have a history of an enlarged prostate or kidney stones?
Patient: No.
Doctor: I would like to get some imaging done.
Patient: Okay.

assistant: Left flank pain and unable to urinate.
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 he ever had any mental retardation problems in the past?
Guest_family: No.
Doctor: Did he go through mainstream education?
Guest_family: Yes, he graduated high school last year. He had an I E P. He has a job now.
Doctor: Oh really. That's great.
Guest_family: We went through a program for the disabled to find him the job. He is doing well.
Doctor: What is the job?
Guest_family: He works at cardboard shop.
Doctor: So, he is ambulatory. No issues with performing the work.
Guest_family: No! His boss said he is doing very well.

assistant: Mainstream high school education, no mental retardation, ambulatory, works at cardboard shop for the disabled.
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: And you are-
Guest_family: Hi, I am her nurse.
Doctor: So, do you know about her past medical history?
Guest_family: I have very limited information, as I very recently started working with her. She does have dementia and that's the main reason why I was hired. Her family wanted someone to look after her twenty four seven.
Doctor: Oh, I see.
Guest_family: But I do have her medical records. You can have a look.
Doctor: Yeah, that will be nice. Let me check her reports quickly. She has a history schizophrenia, chronic anemia and hypothyroidism and she also suffers from asthma.
Guest_family: Yes.
Doctor: Oh, I also see here she tested positive for P P D, was she diagnosed with tuberculosis?
Guest_family: I honestly don't know, but I wasn't told that.
Doctor: Okay.

assistant: Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.
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: Your last visit was on April seventh two thousand five, correct.
Patient: Ah no, it was on April eighth two thousand five, doctor.
Doctor: That's right. So, has anything changed since then?
Patient: No, everything is the same really.

assistant: Essentially unchanged from my visit of 04/08/2005.
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:
Guest_family: What do you think doctor, what does she have?
Doctor: Well, I think she has hay fever. Otherwise she looks like a healthy two year old.
Guest_family: Hm, okay.

assistant: Allergic rhinitis. Otherwise healthy 2-year-old young lady.
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: Hello, sir. I'll be your doctor today. How are you feeling?
Patient: Um uh who? Where am I?
Doctor: You're in the emergency room.
Patient: I'm where?
Doctor: The police found you outside of the local bar. Do you remember what happened prior to your arrival here?
Patient: I'm no longer at the bar?
Doctor: No, you're here because someone was worried you may need medical attention.
Patient: I don't know what's going on. Can you call my girlfriend? She was there with me before we got into a fight.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: How's your husband doing?
Patient: He's good. He usually comes with me to my appointments, but he had to run some errands this morning.
Doctor: Happy to hear that he's also doing well.
Patient: Me too.
Doctor: I just have one more question for you regarding your social history. Do you smoke?
Patient: No, never.
Doctor: Okay, so no changes.

assistant: She is married. She is a nonsmoker.
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: How are you feeling today?
Patient: I am doing good, considering.
Doctor: Are you sleeping well?
Patient: Yes. I was able to get some good sleep last night.
Doctor: Have you been able to eat without any trouble?
Patient: Yes. I ate a little bit of breakfast this morning.
Doctor: Have you been able to have a bowel movement yet?
Patient: Yes, I did this morning.
Doctor: Did you experience any difficulties with your movement?
Patient: It was still a little difficult and hard.
Doctor: Okay. Continue the high fiber diet that we discussed, and it should improve. Please let me or one of the nurses know if it has not improved or becomes worse.

assistant: The patient has been eating fairly well, sleeping well, doing well with her sprints. A little difficulty with her stools hard versus soft as mentioned with the diet situation up in HPI.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GYNHX

Dialogue:
Doctor: So, do you remember when your last pap smear was?
Patient: I have it written down right here in my notes. It was in October of two thousand one.
Doctor: Great, do you have any children?
Patient: Yes, I have a beautiful daughter.
Doctor: That's wonderful. Have you only been pregnant once?
Patient: Yes, I've just pregnant once and it was with my daughter.

assistant: Last pap performed 10/2001. Gravida: 1. Para: 1.
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: Have you undergone any surgeries?
Patient: I had both my tubes tied in O one and I had a polyp removed when I was fourteen.
Doctor: And that was a-
Patient: Oh, sorry I didn't mean to interrupt.
Doctor: It's alright. I just wanted to know if that polyp was found in your colon?
Patient: Yes, it was.

assistant: Bilateral tubal ligation in 2001, colon polyp removed at 14 years old.
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: Where's your rash?
Patient: All over my torso and arms.
Doctor: When did you first notice it?
Patient: Well, it started on my back and then it made its way to my torso and arms.
Doctor: Have you found yourself itching it?
Patient: Yes.
Doctor: Any potential triggers for the rash, such as dietary changes, new medications, or unfamiliar exposures?
Patient: Nope. I mean I did remove some insulation in my basement a few days ago, but I didn't feel itchy that day.
Doctor: Any shortness of breath, wheezing, facial swelling, tongue or lip swelling, or other associated symptoms?
Patient: No.

assistant: This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. No facial swelling. No tongue or lip swelling. No shortness of breath, wheezing, or other associated symptoms. He cannot think of anything that could have triggered this off. There have been no changes in his foods, medications, or other exposures as far as he knows. He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that 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: ALLERGY

Dialogue:
Doctor: Are you allergic to anything?
Patient: As in drugs?
Doctor: Yes, sorry. I was referring to drug allergies.
Patient: Oh yeah. I'm allergic to Sulfa drugs.
Doctor: What happens when you take Sulfa drugs?
Patient: Break out in a terrible rash. I remember I had to go to the E R the first and last time I took it.
Doctor: Wow, I'm sorry. Rashes can be very uncomfortable and sometimes require immediate attention.
Patient: Yeah, so no more Sulfa drugs for me. That's for sure.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you smoke?
Patient: Yes.
Doctor: How much do you smoke?
Patient: Honestly, I smoke every day.

assistant: The patient current smokes.
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 any of your family member have any major medical problems?
Patient: Yeah, my mother died of heart attack. She was seventy years old. My father died of cancer; it was prostate cancer. He was around eighty.
Doctor: Anything anyone else?
Patient: Hm, my brother had both heart disorder and prostate cancer and he died around seventy four.

assistant: Mother died of MI, age 70. Father died of prostate cancer, age 80. Bother died of CAD and prostate cancer, age 74.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: CC

Dialogue:
Doctor: Where's your pain?
Patient: Right above my belly button. It's been bothering me for three weeks now.
Doctor: Does the pain come and go?
Patient: Um it's pretty constant, but it does seem to get worse at night.
Doctor: Do you find that sitting or laying down in certain positions helps the pain?
Patient: Eh not really. I can't seem to really get comfortable since it started.
Doctor: Have you taken any medicine for the pain?
Patient: I uh-
Doctor: Yes?
Patient: Um I took Pepto Bismol a few times, but that didn't do much.
Doctor: Did they already take you back for your C T scan?
Patient: Yeah.
Doctor: We should be getting the results of your scan fairly soon then. In the meantime, I'm going to put in some additional orders.

assistant: Abdominal pain and discomfort for 3 weeks.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Patient: Good morning, doctor.
Doctor: So, I've reviewed your past notes, are there any other diagnoses I should know about?
Patient: Well, I've had depression for a while now.
Doctor: Thank you for sharing that with me.

assistant: Depression