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: Sir? Can you hear me? Are you Mister Smith's wife?
Guest_family: Yes. I am his wife.
Doctor: How old is he? Can you tell me a little bit of how your husband's condition has come to this point? His level of consciousness is concerning.
Guest_family: He is eighty five. He took the entire M G of Xanax. He is only supposed to take point one twenty five M G of Xanax. That is why he is like this.
Doctor: It looks like your husband was admitted to the emergency room the night before. How did these injuries to his face happen?
Guest_family: He fell off his wheelchair.
Doctor: The Adult Protective Services said they found your husband in the home barley conscious. How long had he been that way?
Guest_family: All day.
Doctor: Do you know what other medications your husband has taken other than the Xanax?
Guest_family: He didn't take his regular medications for two days.

assistant: The patient is an 85-year-old male who was brought in by EMS with a complaint of a decreased level of consciousness. The patient apparently lives with his wife and was found to have a decreased status since the last one day. The patient actually was seen in the emergency room the night before for injuries of the face and for possible elderly abuse. When the Adult Protective Services actually went to the patient's house, he was found to be having decreased consciousness for a whole day by his wife. Actually the night before, he fell off his wheelchair and had lacerations on the face. As per his wife, she states that the patient was given an entire mg of Xanax rather than 0.125 mg of Xanax, and that is why he has had decreased mental status since then. The patient's wife is not able to give a history. The patient has not been getting Sinemet and his other home medications in the last 2 days.
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 have you been feeling? Is the Wellbutrin keeping your mood stabilized?
Patient: I have been feeling good. The Wellbutrin is working well for me.
Doctor: It is important to not consume any alcohol or recreational drugs while taking Wellbutrin.
Patient: I don't drink or do drugs.

assistant: The patient has a history of depression. No history of substance abuse.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Tell me a little bit about your family history.
Patient: My dad and grandpa both had type two diabetes. My son is struggling with type one diabetes at the moment.
Doctor: I'm sorry to hear that. Does anyone in your family have heart problems?
Patient: No.
Doctor: How about cancer?
Patient: Two of my cousins had breast cancer.

assistant: As far as heart disease there is none in the family. As far as cancer two cousins had breast cancer. As far as diabetes father and grandfather had type II diabetes. Son has type I diabetes and is struggling with that at the moment.
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, miss?
Patient: Well, you see, I am a civil engineer. Right now, due to pandemic like everyone else I am working from home.
Doctor: Are you working full time or is your disability affecting that?
Patient: No, I can only work on half time. This disability does not let me work full time. I need to go to physical therapy quite frequently on and off and I also have a baby who consumes a lot of my time.
Doctor: Do you smoke or drink?
Patient: No, I've never done any of them.

assistant: The patient is a civil engineer, who currently works from home. She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby. She does not smoke and does not drink and has never done either.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you know any familiar diseases in your family?
Patient: Do you mean like B P, high sugar?
Doctor: Yes.
Patient: No, no one in my family has anything like that.
Doctor: Great.

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

user: Section: ROS

Dialogue:
Doctor: Have you had any anxiety attacks lately?
Patient: No.
Doctor: Have you felt depressed or had any mood swing problems?
Patient: No.
Doctor: Any phobias?
Patient: No, not really.
Doctor: Okay.

assistant: PSYCHIATRIC: Normal; Negative for anxiety, depression, or phobias.
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 today? You still look a little uncomfortable. Is there still pain?
Patient: Yeah. Still a good amount of pain. I did not take my pain medication this morning though. Not sure if that will make a huge difference.
Doctor: That is possibly why you are still in pain. How is movement? Can you get out of the house and get around?
Patient: Yes. I am quite happy that I can do my daily activities. I can get up with minimal assistance and do many activities out of the house. I think I am gaining muscle from moving around more too.
Doctor: How is the home exercise program going?
Patient: I am loving pool therapy. I really feel like that is helping. I do the home exercises sometimes twice a day. I really want to get back to normal.

assistant: The patient states pain still significant, primarily 1st seen in the morning. The patient was evaluated 1st thing in the morning and did not take his pain medications, so objective findings may reflect that. The patient states overall functionally he is improving where he is able to get out in the house and visit and do activities outside the house more. The patient does feel like he is putting on more muscle girth as well. The patient states he is doing well with his current home exercise program and feels like pool therapy is also helping 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: FAM/SOCHX

Dialogue:
Doctor: Are you sexually active?
Patient: Yes.
Doctor: How many partners do you have?
Patient: Just one.
Doctor: Is this a monogamous relationship?
Patient: Yes.
Doctor: What gender is you partner?
Patient: He is a male. We have been together for three years. He is H I V positive.

assistant: Homosexual, in monogamous relationship with an HIV infected partner for the past 3 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: PASTSURGICAL

Dialogue:
Doctor: I remember you mentioned that you had one operation done in the past.
Patient: I had a lymph node biopsy back in September of O three.
Doctor: Did it come back negative?
Patient: Fortunately, yes.

assistant: Excisional lymph node biopsy (9/03).
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: It looks like you have an extensive medical history.
Patient: I blame my heart. It's caused me the most trouble. I had coronary artery bypass surgery in twenty ten along with an angioplasty.
Doctor: I'm sorry that your heart has been giving you so much trouble. I'm happy that you're here with us today and taking the right measures to keep yourself healthy.
Patient: Oh, and I forgot to mention that I've had prostate biopsies in the past.
Doctor: When did you have the biopsies done?
Patient: Last year.
Doctor: Did they come back negative?
Patient: Yes, fortunately. I guess my prostate isn't as troublesome as my heart.
Doctor: I understand.

assistant: Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.
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 medical problems?
Patient: Let's see. I have diabetes, high blood pressure, high cholesterol, and osteoporosis.
Doctor: And any surgeries?
Patient: Several.
Doctor: Which ones?
Patient: I had my tonsils taken out when I was a kid. I also had my uterus removed along with my ovaries and fallopian tubes. The list goes on. I had my appendix removed and two or three of my parathyroids taken out. Despite getting some of my parathyroids removed, I still have borderline high calcium levels according to my endocrinologist.
Doctor: Did you experience any complications during or after surgery?
Patient: No. I forgot to mention that I had two carpel tunnel releases as well.

assistant: She has also had a hysterectomy, salpingoophorectomy, appendectomy, tonsillectomy, two carpal tunnel releases. She also has had a parathyroidectomy but still has had some borderline elevated calcium. Also, hypertension, hyperlipidemia, as well as diabetes. She also has osteoporosis.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: What is your family medical history?
Patient: My mother passed away from complications with Huntington Disease. She was diagnosed and had been having treatments at U I H C. My grandmother and two of my aunts also passed away from Huntington as well.
Doctor: I am so sorry. Do you have siblings?
Patient: Yes! I have one sister. She is thirty eight. She has a lot of metal issues. She has attempted suicide two times.
Doctor: Are you close with her?
Patient: No. Not really.
Doctor: Are you married?
Patient: Yes.
Doctor: Do you have children?
Patient: Yes. We have two adopted kids.

assistant: Mother died age 60 of complications of Huntington Disease (dx at UIHC). MGM and two MA's also died of Huntington Disease. His 38 y/o sister has attempted suicide twice. He and his wife have 2 adopted children.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Any medical problems on your mom or dad's side?
Patient: My dad has lupus and his brother has Addison's disease. High blood pressure also runs in the family.
Doctor: Is your dad being treated for lupus?
Patient: Yes, he follows up with his rheumatologist pretty regularly.

assistant: HTN, father with SLE, uncle with Addison's Disease.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: EXAM

Dialogue:
Doctor: I will do a quick exam on you.
Patient: What kind of exam?
Doctor: I'm just checking for lymph nodes. Whenever there is an infection those guys are the first ones to be noticed with swelling.
Doctor: Okay, so let's first check your neck area. It looks good. I don't feel any inflamed lymph node. Your armpits look good too and the last place to check is your groin area. It is all good. No sign of infection.

assistant: LYMPH: No neck, axillary or groin adenopathy was noted.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: MEDICATIONS

Dialogue:
Doctor: What are some medications you are on?
Patient: I am on pain pills.
Doctor: Do you know their names?
Patient: Yes. Oxycontin and Vicodin.
Doctor: Okay that helps.

assistant: OxyContin and Vicodin.
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: I am looking at the list of your medication.
Patient: Okay.
Doctor: All I can see is Risperdal and Invega.
Patient: I think that is correct.
Doctor: Are you not taking anything else?
Patient: Yes, I take some multivitamins, but do I need to mention it?
Doctor: Yes, you should. We need to know everything.
Patient: Okay.

assistant: Listed as Invega and Risperdal.
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.
Patient: Oh, good morning, doctor.
Doctor: Please, tell me about your living situation.
Patient: Well, right now, I live at home with my kids and my dad.
Doctor: I see here that you're not able to go up the stairs well, can you tell me more about that?
Patient: Yeah, I can't use the stairs without holding the rail the entire time.
Doctor: Holding the rail makes navigating the stairs easier?
Patient: Yeah, but I still move very slow.
Doctor: I see. Do you smoke?
Patient: Yeah, I smoke about a pack to a pack and a half a day.
Doctor: What about exercise? Do you workout?
Patient: No, I don't regularly workout, I've never been good at it.

assistant: The patient lives in a private home with children and her father. The patient states that she does have stairs to negotiate without the use of a railing. She states that she is able to manage the stairs, however, is very slow with her movement. The patient smokes 1-1/2 packs of cigarettes a day and does not have a history of regular exercise routine.
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:
Patient: My physician did a blood test. My potassium is high. He recommended me to meet you.
Doctor: Okay. I did not get the blood report yet. I am waiting for your doctor's office to send it to me. Is it only your potassium that is elevated?
Patient: Yes, that's what they told me.

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

user: Section: DIAGNOSIS

Dialogue:
Guest_family: He was going to buy me a surprise but met with this car accident.
Doctor: I am sorry! He does have multiple trauma due to the accident, and he will require aftercare.
Guest_family: Yeah.

assistant: Aftercare of multiple trauma from an motor vehicle accident.
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, what is your family's living situation at home?
Guest_family: Um, he lives at home with me, and his father.
Doctor: May I assume that you are his biological parents?
Guest_family: Yes, that's correct.
Doctor: Great, does he have any siblings?
Guest_family: No, right now, he's an only child.
Doctor: What grade is he in?
Guest_family: He's in the third grade.
Doctor: Great, and is he doing well in school?
Guest_family: Yes, he's doing quite well.

assistant: lives with biologic father and mother. No siblings. In 3rd grade (mainstream) and maintaining good marks in schools.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Good afternoon, what gender do you identify with?
Patient: Thank you for asking, I identify as a female.
Doctor: Thank you. Do you know of any chronic illnesses?
Patient: No, but can you give me some examples of what you mean?
Doctor: Well, high blood pressure, osteoarthritis, diabetes, depression, anything like that ring any bells?
Patient: Oh, no, I don't have anything like that.

assistant: She claims no chronic 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: PASTMEDICALHX

Dialogue:
Doctor: Do you have any major medical conditions that I should know about?
Patient: What, like cancer?
Doctor: It doesn't have to be that serious, but is there anything you take medicine for?
Patient: Oh, I have allergies and asthma.

assistant: Asthma and 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: Can you tell me something about your mom and dad? Like any diseases they have had?
Patient: Sure, my dad died of heart attack when he was sixty five and my mom died of stroke when she was seventy.
Doctor: How's about siblings, miss? Any health issues?
Patient: No, my brother is healthy.

assistant: Basically unchanged. Her father died of an MI at 65, mother died of a stroke at 70. She has a brother, healthy.
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: Tell me, what's going on?
Guest_family: She is complaining of weakness on the right side of her face.
Patient: And I feel the right side is drooping.
Doctor: Okay, let me look at it.

assistant: Right-sided facial droop and 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: GENHX

Dialogue:
Doctor: My chart here says that you're eighty three years old, is that correct, ma'am?
Patient: Yes doctor, that's correct, I just had my birthday.
Doctor: Happy belated birthday! How have you been doing since your last visit?
Patient: Well, my cancer hasn't needed phlebotomies for several months now, which is good.
Doctor: That's great, you have been treated for polycythemia vera, correct?
Patient: Yes, that's the one.
Doctor: I also see you're unassisted today, which is also great.
Patient: Yeah, having some independence is nice.

assistant: The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months. The patient comes to clinic unaccompanied.
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, do you have any family history of cancer?
Patient: Well, yes, but I can't remember who had what kind.
Doctor: Still, that's helpful, thank you. What about heart disease?
Patient: That too, there's some history of heart disease, but I can't remember who.

assistant: 1. Cancer. 2. Coronary artery disease.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: As far as you know, are there any major health conditions that you know about?
Patient: What do you mean by that?
Doctor: Anything like cancer, or arthritis, do those sound familiar?
Patient: Oh, um, no nothing like that.

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

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Do you have any medical history that we should be aware of?
Patient: I have type two diabetes. My numbers always come high.
Doctor: Okay, anything else?
Patient: I also have high cholesterol.
Doctor: Okay.

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

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Hello. How are you feeling today?
Patient: Great. I'm just here for my yearly physical.
Doctor: Oh, good. I see your past medical history is missing. Do you, by chance, know if you've had any health related problems before?
Patient: Uhm. Let me check my notes on my phone. I knew this question would pop up, but I always forget. Oh, perfect. You can take a look at them.
Doctor: Thank you. I just want to verify the information with you. You had asthma, nasal inflammation, and some abnormal growth on you neck, correct?
Patient: If it's on there, then it's true. I usually don't remember these kinds of things. My wife is usually here with me. She knows all about my health.

assistant: Significant for asthma, allergic rhinitis and cervical dysplasia.
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 the little one doing?
Guest_family: She is doing okay.
Doctor: How long was your pregnancy?
Guest_family: Thirty six weeks.
Doctor: Was your delivery normal or C section?
Guest_family: It was a C section.
Doctor: How much did she weigh?
Guest_family: She was eight pounds and three ounces.
Doctor: Tell me what's the issue?
Guest_family: Yeah, she has a history of seizures. It looks like she is having pain in her tummy and is throwing up.
Doctor: What else did you notice?
Guest_family: It looks like she is having some rashes on her skin. There is vomiting for sure. She also feels bloated. She also complains of pain in her tummy. Sometimes she does scratch her mouth. We also noticed some swelling around her lips, eyes and face.
Doctor: It looks like she's having some food intolerance.

assistant: Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces. She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: MEDICATIONS

Dialogue:
Doctor: What medications are you taking right now?
Patient: I am taking Advair and Allegra.
Doctor: Okay is it helping you?
Patient: I don't know, I am not sure the Allegra is helping. But I do take them regularly.
Doctor: But is it like better than Claritin?
Patient: Yes, I think so.
Doctor: Okay that's good.
Patient: Shall I continue?

assistant: Advair and Allegra. He has been taking these regularly. He is not sure the Allegra is working for him anymore. He does think though better than Claritin.
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: Anybody sick in family?
Patient: No one.
Doctor: How about any illnesses that run in your family?
Patient: No, everyone is healthy.

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

user: Section: CC

Dialogue:
Doctor: Hi again! How has your acne been since you started the spironolactone?
Patient: It has been improving.
Doctor: Have you experienced any increased thirst, mood changes or unusual fatigue?
Patient: No.

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

user: Section: EDCOURSE

Dialogue:
Doctor: Well, I don't think you need any restraints as you are doing fine. I do want to make sure you have a chair and bed monitor since you have a history of multiple falls. They can help detect fall.
Patient: I don't want that, I will manage.
Doctor: Are you sure?
Patient: Yes!

assistant: RESTRAINTS: None. The patient has declined use of chair check and bed check.
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: Hi there! How are you today?
Patient: Hi! I am good.
Doctor: Welcome in!
Patient: Thank you.
Doctor: Lets start with a little social history. Are you a tobacco or alcohol user?
Patient: No.
Doctor: Are you married? Do you have children?
Patient: I am not married but I do have a two year old son.
Doctor: Do you currently see a gynecologist?
Patient: Yes. She is in Bartow.
Doctor: Great.

assistant: She is followed by a gynecologist in Bartow. She is not an alcohol or tobacco user. She is not married. She has a 2-year-old child.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Welcome in.
Patient: Thank you.
Doctor: Do you smoke?
Patient: No, I don't. Smoking is gross.
Doctor: I agree. Do you drink alcohol?
Patient: Yes.
Doctor: How much do you drink per day or week?
Patient: When I get off work usually have a glass of wine. I don't ever have more then one glass.
Doctor: Okay.

assistant: She does not smoke. She takes one glass of wine per day.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: EDCOURSE

Dialogue:
Doctor: The nurse applied antibiotic ointment and a bandage to your foot. Did she go over how to change the bandage at home?
Patient: Yes.

assistant: The patient had antibiotic ointment and a bandage applied to his foot.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Hello. Before we begin, I need you to confirm some information for me.
Patient: What kind of information?
Doctor: About your family. Do you know if you have certain medical conditions that run in your family?
Patient: Nope. My family is very healthy.

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

user: Section: MEDICATIONS

Dialogue:
Doctor: How about any breathing issues or asthma?
Patient: Actually, I have a history of asthma.
Doctor: Oh okay, and was it severe or mild?
Patient: Well, it was not severe but still remarkable.
Doctor: Hm, alright. Anything else?
Patient: Yes, I also struggled with a serious acne problem.
Doctor: Got it.

assistant: Significant for asthma and acne.
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's she doing?
Guest_family: She's had better days.
Doctor: Aw and why's that?
Guest_family: She's been really congested recently. Snorting a lot more, too. She's onlt eleven and I think it is odd she snores so much. I took her to see the allergist and he said it's not her allergies so we stopped giving her Allegra.
Doctor: Does she happen to snore at night?
Guest_family: No, not really.
Doctor: Hm.
Guest_family: And while we're here, I also wanted you to check out her toe. The right big toe appears a bit red to me. The skin around it has been peeling for the last week and a half.
Doctor: Lemme take a look. Have you applied anything to the area?

assistant: This is an 11-year-old female who comes in for two different things. 1. She was seen by the allergist. No allergies present, so she stopped her Allegra, but she is still real congested and does a lot of snorting. They do not notice a lot of snoring at night though, but she seems to be always like that. 2. On her right great toe, she has got some redness and erythema. Her skin is kind of peeling a little bit, but it has been like that for about a week and a half now.
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: Why are you holding your face?
Patient: Ah! Have pain in my tooth.
Doctor: Oh, how bad is it?
Patient: Oh, awfully bad.
Doctor: I am so sorry.

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

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Have you had similar symptoms before?
Patient: No never like this.
Doctor: Any other complaints you have had in the past?
Patient: Just some knee pain issues.
Doctor: Okay, so chronic knee pain.
Patient: Yes.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Can you tell me about any cancers in your family?
Patient: Yes, my sister has ovarian cancer, and my father has liver cancer.
Doctor: Oh I am so sorry.
Patient: That is okay.
Doctor: Any heart conditions?
Patient: My mom and dad both have heart disease. My dad has diabetes too.

assistant: Consistent with a sister of his has ovarian cancer and his father had liver cancer. Heart disease in the patient's mother and father, and father also has 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: PASTMEDICALHX

Dialogue:
Doctor: Can you tell me what problems you have had in the past. Or what medical issues are currently going on?
Patient: You mean my heart problem and things?
Doctor: Yes.
Patient: Okay, I have hypertension and kidney problems since many years.
Doctor: Okay.
Patient: I get frequent urinary infections.
Doctor: Your urine creatinine is normal.
Patient: Okay. I also have severe aortic stenosis.

assistant: Significant for moderate to severe aortic stenosis, urinary tract infection, hypertension, chronic kidney disease (although her creatinine is near normal).
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Does anyone else in your family have aneurysm problem?
Patient: Well, my grandmother had it. She actually passed away due to brain aneurysm.
Doctor: Oh, okay.

assistant: Grandmother died of cerebral aneurysm.
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 is wrong with your back honey?
Patient: Oh, it all started off with a little pimple on the buttock. I was soaking it at home with hot water and stuff, but it did not improve. I hope this is not cancer. I am only twenty four.
Doctor: Okay what exactly are you experiencing?
Patient: I have pain.
Doctor: So you came to the hospital on the first and they did an I and D in E D?
Patient: Yes I was admitted to the hospitalist service with high blood sugars. My African American father was so scared.
Doctor: Okay sugars high. Do you know the number? How high?
Patient: No, I do not know that but they found positive bacteria or some sort of thing in my blood culture.
Doctor: So today we are evaluating you for surgery?
Patient: Yes.

assistant: This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The patient underwent incision and drainage in the emergency department. She was admitted to the hospitalist service with elevated blood sugars. She has had positive blood cultures. Surgery is consulted today for evaluation.
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 there! I have the results from your ultrasound. You have kidney stones in the ureter close to the bladder.
Patient: Oh no.
Doctor: This explains the pain you have been having on your left side. Are you still experiencing nausea and vomiting?
Patient: Yes, I have been.
Doctor: I would like to set you up with a consult with a consult with a surgeon.
Patient: Okay.

assistant: 1. Left flank pain. 2. Left ureteral stone. 3. Nausea and vomiting.
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: Your daughter had an exposure to the ant bait but we are not sure if she actually ingested any of it. Poison Control confirmed that even if she did ingest the small amount that she was found with, it is likely nontoxic. Do you have any questions?
Guest_family: No.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Hello, sir. How are you today?
Patient: I am alright. I am here for a check up since I am feeling kind of dizzy lately.
Doctor: That is not good. How long has this been happening?
Patient: A few months. This happened to my sister too. I think she is still dealing with it.
Doctor: Is there any other family medical history I should know about? Migraines or cancer?
Patient: No. Not that I know of. The rest of my family seems pretty healthy.

assistant: Sister is dizzy but no other acute 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: LABS

Dialogue:
Doctor: Okay so your blood report is back and the cardiac enzyme we were looking for are negative.
Patient: Okay.
Doctor: Your blood urea nitrogen, also known as B U N, is within normal limits and hydrogen is stable. Creatinine is also within the normal range.
Patient: Great!

assistant: First set of cardiac enzyme profile negative. H&H stable. BUN and creatinine within normal limits.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Hi, how are you doing today?
Patient: I've been better. Thank you.
Doctor: So, you are here for your follow up right? Remind me how often are you coming here?
Patient: That's right. I'm coming around between a month or two.
Doctor: Yeah, it's every four to eight weeks.
Patient: I'm not taking any medicine now. I just wanted to let you know.
Doctor: Yeah, I can see it in your record. It says that you are off of all the immunosuppression. So, just let me check. It says here that you do have mild chronic G V H D. It is not that bad that I should be worried about any therapy or anything else. How long ago did you get that transplant?
Patient: I think it was around four and a half years ago. I'm feeling much better after that. I do have complaints of blood in my stool. But after you sent me to that doctor, that gastro doctor, I feel good. I know they said that they removed something, but I'm not sure, but after that it has been improved a lot.
Doctor: Okay, let me see in my chart. You had some rectal bleeding issues because of which I referred you to the gastroenterologist. A complete endoscopy was performed, which was both on the upper and the lower side. There was no evidence of ulcers or any other abnormality. That's good news, right?
Patient: Yeah, I agree. That was a relief.
Doctor: They did find some polyps and they removed it. They turned out to be benign, so nothing to worry about there.
Patient: Yeah, I remember this said they removed something, but I forgot the name.
Doctor: Is there any other issue that I can help you with?
Patient: I don't know. I feel a lot of fatigue and like I'm not able to do things like I used to do before. I get tired very easily. I don't know if it is related to something or not, but things have been weird. I'm not able to do even the minor things like I lift two boxes and I'm done for the day. Is it something that I should be worried about?
Doctor: It looks like you have a mild iron deficiency. I will work on that with you, don't worry.

assistant: The patient comes to the clinic today for followup. I am seeing him once every 4 to 8 weeks. He is off of all immunosuppression. He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant. He has multiple complaints. He has had hematochezia. I referred him to gastroenterology. They did an upper and lower endoscopy. No evidence of ulcers or any abnormality was found. Some polyps were removed. They were benign. He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: EDCOURSE

Dialogue:
Doctor: Are you feeling any pain?
Patient: No, I feel great.
Doctor: Is there any other medical issue that we should be worried about?
Patient: No, it feels like I'm young again. I'm able to do all my activities.

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

user: Section: GENHX

Dialogue:
Doctor: Thank you for coming in to see us at A B C D General Hospital today.
Patient: I wish I wasn't here right now.
Doctor: I understand, before we begin, how old are you?
Patient: I'm seventy seven years young.
Doctor: Which race, and gender do you identify with?
Patient: I'm an African American woman.
Doctor: What's seems to be causing you pain today?
Patient: I've had this bunion on my foot for as long as I can remember.
Doctor: Is the pain worsening?
Patient: Yes, it is so painful, I've tried to avoid surgery for so long, but I want this bunion gone.
Doctor: How have you managed this bunion in the past?
Patient: I've used antiinflammatories, rested, changed my activities, I've done everything, but this pain is getting worse and worse. I need it gone.

assistant: This 77-year-old African-American female presents to ABCD General Hospital. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful. The patient has attempted conservative treatment without long-term relief of symptoms and desires surgical treatment.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: How are you dealing with your pain now?
Patient: Oh no, I have no issues with my pain. Today I'm here for a different cause. I'm having this weakness all around on my left side, especially in my arm. I feel like I cannot lift anything like even a glass of water. It's hard for me to lift it up. I'm not able to walk properly, let alone the balancing and everything else. It's just that my whole left side seems to be weak.

assistant: The patient reports that the pain is not an issue at this time. The patient states that her primary concern is her left-sided weakness as related to her balance and her walking and her left arm 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: PASTMEDICALHX

Dialogue:
Doctor: Did you have any medical disorders previously, sir?
Patient: I have diabetes. Also, I was quite overweight.
Doctor: Are you taking any medications for that?
Patient: Yes, I was still taking something called Zyprexa, but I stopped it after my last regular weight check. Also, I never took anything for diabetes. I also have chronic bronchitis for… I don't know… many years.
Doctor: Do you smoke?
Patient: Oh yes, I am a smoker.
Doctor: How many cigarettes do you take in a day?
Patient: Maybe up to sixty a day.

assistant: He has a history of obesity and also of diabetes mellitus. However, most recently, he has not been treated for diabetes since his last regular weight since he stopped taking Zyprexa. The patient has chronic bronchitis. He smokes cigarettes constantly up to 60 a 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: ROS

Dialogue:
Doctor: Lets talk about your ears. Any continuous ringing or thumping noises you may hear?
Patient: No, nothing like that.
Doctor: Any hearing problems?
Patient: Um, no.
Doctor: Any dizziness or spinning sensation?
Patient: Nope.

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

user: Section: GENHX

Dialogue:
Doctor: Good morning, ma'am. You're eighty two years old, is that correct?
Patient: Good morning, doctor. Yes, that's correct.
Doctor: Good, and just one more piece of background information, which hand do you write with?
Patient: I use my right hand for everything.
Doctor: Good, so what seems to be the problem today?
Patient: Doctor, I've had years of pain in this shoulder.
Doctor: What kind of treatments have you had?
Patient: Well, um, I've had antiinflammatories, and rested, and none of it has helped so far.
Doctor: Can I assume the pain is impacting your daily life?
Patient: Yes, it certainly is. The pain is unbearable now.

assistant: The patient is an 82-year-old right-hand dominant female who presents for shoulder pain for many years now and affecting her daily living and function and pain is becoming unbearable failing conservative treatment.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTSURGICAL

Dialogue:
Doctor: Have you ever had surgery?
Patient: What, like a joint replacement?
Doctor: Well, anything from joint replacements, to appendix removal, or C sections?
Patient: Yeah, I've had an appendectomy and hysterectomy, actually.

assistant: The patient has a past surgical history of appendectomy and hysterectomy.