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: Good morning, sir. You're sixty one years old, correct?
Patient: Good morning, doctor. Yes, that's correct.
Doctor: Great, and you identify as Caucasian, right?
Patient: Yes, that's correct as well.
Doctor: Thank you, do you have any medical conditions that I should know about?
Patient: Yes, I have diabetes.
Doctor: How are you handling your diabetes?
Patient: Well, I've had diabetes for a long time but had never been treated for it.
Doctor: Okay, thank you for telling me. What seems to be the problem today?
Patient: I've been working in my garage over the past few days, and I have this redness and swelling in my right foot.
Doctor: Do you have any itchiness or pain?
Patient: Yes, and it's getting worse.
Doctor: Have you seen any other doctors about this?
Patient: Um, yes. I went to the A B C D General Hospital E R and they gave me an evaluation there.
Doctor: Do you have any images from this visit?
Patient: Um, yes. I have them right here.
Doctor: Okay, these show a foreign body in the foot.
Patient: But what about all the stuff on the outside of my foot?
Doctor: Well, that's consistent with cellulitis.
Patient: What's that?
Doctor: It's a skin infection we clean it up in surgery.
Patient: What kind of procedure can we do?
Doctor: We should do an irrigation debridement for the cellulitis, and remove the foreign body. I think that will really help.
Patient: Yes, I agree, doctor.

assistant: The patient is a 61-year-old Caucasian male with a history of uncontrolled diabetes mellitus. The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot. He notes some itching as well as increasing pain and redness in the right foot and presented to ABCD General Hospital Emergency Room. He was evaluated by the Emergency Room staff as well as the medical team and the Department of Orthopedics. It was noted upon x-ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity. After a long discussion held with the patient, it was elected to proceed with irrigation debridement and removal of the foreign body.
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 doing today?
Patient: I'm flustered. I brought my wife so she can speak for me.
Doctor: Hello, ma'am. What seems to be the problem with your husband?
Guest_family: He's been having some problems with his skin in his private region. He's too shy to talk about it himself.

assistant: The patient is accompanied with his wife.
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, ma'am?
Patient: Yes, to my wonderful husband.
Doctor: Does he help you out around the house?
Patient: Yes, he is just wonderful.
Doctor: So, do you drink or smoke?
Patient: No, I don't do any of that.
Doctor: How about more illicit substances, do you use any of that?
Patient: No, absolutely not.

assistant: She is married and has support at home. Denies tobacco, alcohol, and illicit drug use.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ROS

Dialogue:
Doctor: Anything else going on from head to toe?
Patient: No doctor, everything else is fine.
Doctor: Are you sure?
Patient: Yes I am sure.

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

user: Section: DISPOSITION

Dialogue:
Guest_family: How's my husband doing? Sorry, I had to take a call outside.
Doctor: He's doing much better. He'll be going home today with a prescription for Zithromax.
Guest_family: I'm glad he's able go home and get some rest.
Doctor: However, I'd like to still see him in the office next week for a reevaluation.
Guest_family: Great. Can we make the appointment right now?
Doctor: Yes, the front desk will be able to help you with that.

assistant: The patient was in stable condition and good condition on exam at the time and was discharged home on Zithromax to be followed up in the office within a 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: ROS

Dialogue:
Doctor: How long have you been running a fever?
Patient: It's been on and off for a few days now. I'm also having chills.
Doctor: Have you taken anything for the fever?
Patient: Tylenol and Advil. I've been taking them interchangeably.
Doctor: When was the last time you took your temperature?
Patient: An hour ago. The thermometer read one O one point four.
Doctor: Are you experiencing any other symptoms, such as shortness of breath, nausea, vomiting, diarrhea, or others?
Patient: I've been having a stronger urge to pee a lot more than usual. Not sure if that's related.
Doctor: It could be. We're still waiting on your urine results. Do you have a history of cataracts or glaucoma?
Patient: No.
Doctor: Okay, great. Any signs of pneumonia or valley fever?
Patient: Nothing of the sort.
Doctor: What about blood in your vomit or feces?
Patient: Nope.
Doctor: Any neurological symptoms like T I A or C V A? That is slurred speech or stroke symptoms.
Patient: Luckily, no. I don't have seizures or anything like that.
Doctor: Great to here. With the pandemic I wanted to check on your mental health too. Any depression or anxiety?
Patient: I have always been a homebody. This is normal for me. Nothing like that in my head.
Doctor: Cool. Do you have any issues with blood disorders?
Patient: Nothing like that.

assistant: CONSTITUTIONAL: No history of fever, rigors, or chills except for recent fever and rigors. HEENT: No history of cataract or glaucoma. RESPIRATORY: Shortness of breath. No pneumonia or valley fever. GASTROINTESTINAL: Nausea and vomiting. No hematemesis or melena. UROLOGICAL: Frequency, urgency. MUSCULOSKELETAL: No muscle weakness. SKIN: None significant. NEUROLOGICAL: No TIA or CVA. No seizure disorder. PSYCHOLOGICAL: No anxiety or depression. HEMATOLOGICAL: None significant.
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, miss. It looks like some information is missing for your profile. Is it fine if I ask you a few questions?
Patient: Of course. Go ahead.
Doctor: Do you currently smoke?
Patient: No, I finally stopped smoking cigarettes.
Doctor: Did you smoke before?
Patient: I did. I smoked a half a pack for about twenty years.
Doctor: Well, it's good to hear that you've stopped. I encourage you to continue to not smoke.
Patient: I agree. I need to change up my lifestyle.
Doctor: Last question. Do you drink alcohol?
Patient: No, I don't. I don't like anything that has alcohol. I can't stand the taste of it. If I do it is rare.

assistant: The patient used to smoke cigarettes for about 20 years, one-half pack a day. She currently does not, which was encouraged to continue. She rarely drinks any alcohol-containing beverages.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Hello, sir. So, remind me, how long ago was your procedure?
Patient: Let me think. Now, it's been about four months. I just turned fifty nine.
Doctor: Okay, and just to refresh your memory, we did a percutaneous screw fixation of a Schatzker I V tibial plateau fracture, and we've managed those toe fractures nonoperatively.
Patient: Which toes did I break?
Doctor: You broke your second and fifth toes.
Patient: Do you have the x rays? Can I see where the breaks are?
Doctor: Absolutely, if you look here, right here is where the breaks are. These are called the metatarsal heads.
Patient: Wow, that's right where it hurts.
Doctor: Yep, and where are you living now?
Patient: Thankfully, I left the nursing home, and I'm back in my own house now.
Doctor: That's really good. Are you in any pain today?
Patient: No, not today.
Doctor: Great, have you been going to P T?
Patient: Yeah, I've been going about two or three times a week.
Doctor: Are there any signs of infection, like drainage from the incision?
Patient: Nope, the wound healed up nicely. I'll be able to wear shorts again.
Doctor: Great, are you having any fever symptoms, like cough, runny nose, sore throat, fatigue, anything like that?
Patient: No, but I have had some tingling in both my feet. I don't know if its related to surgery. If I'm remembering the names right, um, I have a history of spinal stenosis and neuropathy in my legs.
Doctor: With your history of spinal stenosis, the broken toes, and the surgery, that's a pretty normal side effect.

assistant: The patient is a 59-year-old gentleman who is now approximately 4 months status post percutaneous screw fixation of Schatzker IV tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures. He is currently at home and has left nursing home facility. He states that his pain is well controlled. He has been working with physical therapy two to three times a week. He has had no drainage or fever. He has noticed some increasing paresthesias in his bilateral feet but has a history of spinal stenosis with lower extremity neuropathy.
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 currently smoke? Or did you smoke in the past?
Patient: Quit in nineteen seventy two.
Doctor: Great to hear. Are you working right now?
Patient: Yeah, I work at a nursing home.
Doctor: Does your job allow you to take time for yourself?
Patient: Yeah, my job is very supportive. I've actually been trying to lose weight. So far, I've lost a good amount since starting a new diet several months back.

assistant: She works at nursing home. She is a nonsmoker. She is currently trying to lose weight. She is on the diet and has lost several pounds in the last several months. She quit smoking in 1972.
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: Hello. Are you ready for your surgery today?
Patient: Can we reschedule? I'm too scared to do it.
Doctor: It'll be fine. Don't worry too much about it. Have you ever had a surgery before?
Patient: Never. What if something goes wrong?
Doctor: You have nothing to worry about. I've done this procedure multiple times, and everyone was fine after.
Patient: Thank you, Doctor. Let's get started then.

assistant: Denied.
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: I don't really remember anyone having any major health problems.
Doctor: Okay.
Patient: Everyone is pretty healthy.
Doctor: That is fortunate.
Patient: Yeah, it is.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: How's it going? I haven't seen you in a long time.
Patient: Hey, Doctor. My headaches have been getting worse.
Doctor: Remind me again. Does you family have a history of migraines.
Patient: I don't think so.
Doctor: Okay. Let's perform some tests.

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

user: Section: GENHX

Dialogue:
Doctor: Hello, this is your follow up visit, right? Welcome back! Have you been taking your Plaquenil for lupus, ma'am?
Patient: Yeah, I am.
Doctor: Your prescription is two hundred M G twice a day, correct?
Patient: Yeah, that's it.
Doctor: Do you have your eye report with you today?
Patient: Yes, doctor. Here you go.
Doctor: Good, thank you, what seems to be the problem today?
Patient: Well, I'm having some aches and pains in my hands and elbows.
Doctor: When did this pain start?
Patient: It's been a few weeks now.
Doctor: Is there any associated trauma? Did you fall?
Patient: No, no falls or anything. It just started one day, and it's really bothering me.
Doctor: Are you having any fever or chills, or cold or flu like symptoms?
Patient: No, I'm not.
Doctor: How about swelling? Are any of your joints swollen?
Patient: No, everything is normal there. Of note, I have been losing a lot of hair recently.
Doctor: Okay, that's interesting.

assistant: The patient is here for a follow-up. The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d. Eye report was noted and appreciated. The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago. She denied having any trauma. She states that the pain is bothering her. She denies having any fevers, chills, or any joint effusion or swelling at this point. She noted also that there is some increase in her hair loss in the recent times.
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, I know you're technically not allowed to drink, but I'm required to ask this anyway. Do you drink at all?
Patient: No, actually. I try to steer clear of drinking while training for my marathon.
Doctor: When is that by the way?
Patient: Next summer.
Doctor: Wow, good luck. It'll be yet another big accomplishment.
Patient: Thank you.
Doctor: And how about smoking of any kind?
Patient: Nope.

assistant: The patient denies smoking and drinking.
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: Let us start with your family medical history.
Patient: I have a lot of diabetes in the family.
Doctor: Who has diabetes?
Patient: My father had diabetes. He passed away.
Doctor: I am so sorry. How did he pass away?
Patient: He had cancer. He actually had breast cancer.
Doctor: That is incredibly rare. Is your mother still with us?
Patient: Yes, she is. She just had her eighty ninth birthday. Next year we are going to plan a big birthday bash for her.
Doctor: Do you have any siblings?
Patient: Yes. I have a sister. She has diabetes too.
Doctor: Do you know of any family members with neurological disorders such as M S, epilepsy, or Huntington's?
Patient: No. I don't know of anything like that.

assistant: His father died from breast cancer. He also had diabetes. He has a strong family history of diabetes. His mother is 89. He has a sister with diabetes. He is unaware of any family members with neurological 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: FAM/SOCHX

Dialogue:
Doctor: How're your other children doing?
Guest_family: Not so wonderful. They're all on antibiotics.
Doctor: For the same?
Guest_family: Yep. They all have ear infections and chest colds.
Doctor: Your hands are full then.
Guest_family: Tell me about it, doctor. I can't seem to catch much of a break.
Doctor: It's definitely been a tough winter for you and your family.

assistant: All siblings are on antibiotics for ear infections and URIs.
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: Is this your mother with you today?
Patient: Yes, this is my mommy.
Doctor: Great, welcome, what did you do this this ankle, young lady?
Patient: Well, I was running when I twisted my ankle.
Doctor: Which ankle did you twist?
Patient: It was my right ankle.
Doctor: Where does it hurt the worst?
Patient: Right here, on the outside of my ankle.
Doctor: Do you have a primary care physician?
Guest_family: Yeah, we go to Doctor Brown.
Doctor: Do you have any other injuries to speak of?
Patient: No, it's just my ankle really.

assistant: The patient was running and twisted her right ankle. There were no other injuries. She complains of right ankle pain on the lateral aspect. She is brought in by her mother. Her primary care physician is Dr. Brown.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Good afternoon, young lady.
Patient: Hello, doctor.
Doctor: What grade are you in, young lady?
Patient: I'm in middle school, um, I'm in the eighth grade.
Doctor: Do you play any sports?
Patient: Yes, I love to play basketball.
Doctor: Good, are both of your parents at home?
Patient: Yes, I live with my mom and dad.
Doctor: Do you have any siblings?
Patient: Yes, I have a little brother, um, he's nine now.
Doctor: Great, have you started your periods?
Patient: Um, yes, my first one was in September.

assistant: She is currently an eighth grader at Middle School and is interested in basketball. She lives with both of her parents and has a 9-year-old brother. She had menarche beginning in September.
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: How many children do you have, ma'am?
Patient: I was blessed with four beautiful children.
Doctor: That's wonderful. Did you have any complications with the pregnancies?
Patient: Actually, I had two c sections for both of my sons.

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

user: Section: GENHX

Dialogue:
Doctor: So, this is your follow up? How are you doing so far with Lamictal?
Patient: Yes, it's the follow up. Lamictal was okay. There was no side effect with that. But I had twitching in my muscles a lot of times. It was not generalized, but I was very afraid that this will happen.
Doctor: What time of day was it? That you had these episodes.
Patient: Mostly in the mornings.
Doctor: I have your recent E E G report. It did show multiple spikes and some complexes on both the sides, but it is more prominent on left.
Patient: I have been taking my medications very regularly and I was getting a good amount of sleep as well.
Doctor: Are you able to drive?
Patient: Yes.
Doctor: Is there any change in your social history or any other symptoms that arise or, or is it same as before?
Patient: Looks same to me.

assistant: The patient returns for followup. Since last consultation she has tolerated Lamictal well, but she has had a recurrence of her myoclonic jerking. She has not had a generalized seizure. She is very concerned that this will occur. Most of the myoclonus is in the mornings. Recent EEG did show polyspike and slow wave complexes bilaterally, more prominent on the left. She states that she has been very compliant with the medications and is getting a good amount of sleep. She continues to drive. Social history and review of systems are discussed and documented on the chart.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTSURGICAL

Dialogue:
Doctor: What types of surgeries have you had in the past?
Patient: I had gall bladder and appendix surgery then they also took out my ovaries.
Doctor: Okay.

assistant: Cholecystectomy, appendectomy, oophorectomy.
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 had any surgeries in the past?
Patient: Yeah, I have, I actually had it to repair an undescended testicle.
Doctor: Oh, wow, do you remember it at all?
Patient: No, nothing about it, I had that done when I was a baby.

assistant: He had a history of surgery for an undescended testicle.
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 cigarettes?
Patient: I don't smoke cigarettes but I do have one on a rare occasion.
Doctor: Do you drink alcohol or use any recreational drugs?
Patient: I don't drink but I do occasionally smoke weed.
Guest_family: He has a drink every now and again when we get together with friends.
Doctor: Okay.

assistant: Married. Rare cigarette use/Occasional Marijuana use/Social ETOH use per wife.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you smoke or drink?
Patient: No, neither.
Doctor: Any history of drug abuse?
Patient: No, I have never used any illegal drugs in my life.
Doctor: Okay.

assistant: She denies the use of alcohol, illicits, or tobacco.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: DIAGNOSIS

Dialogue:
Guest_clinician: Is the patient being admitted for disseminated C M V infection?
Doctor: Yes. I suspect they have possible C M V pneumonitis as well.
Guest_clinician: Are they on immunosuppressants?
Doctor: Yes. They have polymyositis and they're taking Prednisone and Methotrexate.
Guest_clinician: Got it.

assistant: 1. Disseminated CMV infection with possible CMV pneumonitis. 2. Polymyositis on immunosuppressive therapy (methotrexate and prednisone).
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: Alright we already spoke about your past medical history, anything else you might want to add?
Guest_family: Oh, dad did you also talk about your depression?
Doctor: Depression? I don't think we spoke about that.
Patient: Yeah we didn't, it slipped out of my mind.
Guest_family: My father has a history of depression and anxiety.
Doctor: Okay, let me make a note of it.

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

user: Section: CC

Dialogue:
Doctor: How are you?
Patient: Not good.
Doctor: What brings you here today?
Patient: This ulcer in my ankle is just not healing.
Doctor: Is it on both sides?
Patient: No, just on the right side.

assistant: Nonhealing right ankle stasis ulcer.
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 remember the details of your surgery, sir?
Patient: No, can you remind me?
Doctor: We did a left inguinal hernia repair.
Patient: Thank you for reminding me.
Doctor: You have a history of prostate cancer as well, correct?
Patient: Yes, they said it was Gleason, um, three plus four.
Doctor: Yes, that sounds familiar. What medicines are you taking right now?
Patient: I'm taking Lupron, currently.

assistant: 1. He is status post left inguinal hernia repair. 2. Prostate cancer diagnosed in December 2004, which was a Gleason 3+4. He is now receiving Lupron.
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 many people do you have in your family?
Patient: Well, I have four children, all healthy with no medical conditions.
Doctor: Wow, that's great!
Patient: My father passed away at the age of sixty nine due to C V A. And my mom died exactly ten years later, her heart just suddenly stopped. She was seventy nine.
Doctor: Okay. And do you have siblings?
Patient: Well, believe it or not I had eleven siblings, including me twelve.
Doctor: Wow!
Patient: Yes, I lost six of them. Four of them to diabetes, one of my brothers passed away at the age of seventy two and we could never determine the reason my sister died.
Doctor: Hm okay.

assistant: The Father of the patient died at age 69 with a CVA. The Mother of the patient died at age 79 when her "heart stopped". There were 12 siblings. Four siblings have died, two due to diabetes, one cause unknown, and one brother died at age 72 with heart failure. The patient has four children with no known medical problems.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: CC

Dialogue:
Doctor: You are referred for some abdominal infection right?
Patient: Yes, they told me I might have C Diff?
Doctor: Yes that's what we will evaluate you for.

assistant: I was asked to see the patient for C. diff colitis.
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? How old are you?
Patient: I am good, how are you? I am seventy two years old.
Doctor: Good. How can I help?
Patient: Actually, there is a wooden splinter stuck beneath my left fifth fingernail. I am an American farmer by blood, so this has happened before.
Doctor: Oh, when did this happen, sir?
Patient: Yesterday evening around four P M.
Doctor: Okay, then what did you do?
Patient: Then I tried to remove it with tweezers at home, but it did not come out. So, I want you to remove this.
Doctor: Okay let me see.
Patient: Yeah, here.
Doctor: Okay. Can you tell me when the last time you had a tetanus shot?
Patient: Oh it's been so long. I would say it has been over ten years since I have had any tetanus shot.
Doctor: Okay and are you allergic to anything?
Patient: Oh yes. I am allergic to horse serum. I think it is added in vaccinations?
Doctor: Oh, okay.
Patient: But I don't want any tetanus vaccine now.
Doctor: Oh! But you need it.
Patient: I know, but I get a bad reaction to vaccines so I don't want it.
Doctor: Okay. let me fine some alternative.
Patient: Thanks.

assistant: Patient is a 72-year-old white male complaining of a wooden splinter lodged beneath his left fifth fingernail, sustained at 4 p.m. yesterday. He attempted to remove it with tweezers at home, but was unsuccessful. He is requesting we attempt to remove this for him. The patient believes it has been over 10 years since his last tetanus shot, but states he has been allergic to previous immunizations primarily with "horse serum." Consequently, he has declined to update his tetanus immunization.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: IMMUNIZATIONS

Dialogue:
Doctor: Have you had a recent vaccination?
Patient: I had a flu shot last winter but I have not had and recent vaccines.
Doctor: Do you have any planned in the near future?
Patient: I was going to get another flu shot but I don't think I am due for that for another three months.
Doctor: Great.

assistant: Nothing significant.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: How old are you?
Patient: Seventy one.
Doctor: Are you right handed or left handed?
Patient: Right handed.
Doctor: What exactly happened?
Patient: I, I had this bad headache on fifth of November and then I had a big sneeze, like it was too loud. I had-- it was going on for like three to four days. Then, on the seventh, I had this severe pain over my left eye and I kind of lost my vision there.
Doctor: When did you see changes in your eyelid?
Patient: Yeah, on the following day, it seemed like swelling and then my eyelid, it began like pulling down and getting down. Kind of drooping. We went to a local doctor, and he did some x rays.
Doctor: Yeah, I have your brain C T report from there. There is no sign of any kind of bleeding, but I do see a torturous blood vessel there.
Patient: Yeah, after looking at this report they transferred us here to the U I H C on the twelfth.

assistant: 71 y/o RHM developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. The headache lasted 3-4 days. On 11/7/92, he had acute pain and loss of vision in the left eye. Over the following day his left pupil enlarged and his left upper eyelid began to droop. He was seen locally and a brain CT showed no sign of bleeding, but a tortuous left middle cerebral artery was visualized. The patient was transferred to UIHC 11/12/92.
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 see here that you're in for a med refill. Is that correct?
Patient: Yep. I ran out of Klonopin one or two days ago.
Doctor: What are you taking it for? And how long have you been on it?
Patient: Panic attacks. I have really bad episodes without it. Um I think I started it about four months ago. I could be wrong though. I've lost track of time.
Doctor: Who usually prescribes it to you?
Patient: My doctor back in Georgia.
Doctor: Do you happen to have their name or contact info on hand?
Patient: No, unfortunately.
Doctor: How much Klonopin do you take for your panic attacks?
Patient: I take a pretty low dose. I think I'm on zero point five milligrams a day. Is there any way you could verify the dosage?
Doctor: I can try to look it up online. When were you last prescribed Klonopin?
Patient: Over two months ago I think.
Doctor: Let me pull up the page and see if we can figure out your dosage and when you're due for a refill based on your doctor's orders.
Patient: Okay, thank you.
Doctor: Are you experiencing any symptoms currently, such as headache, nausea, vomiting, shortness of breath or chest pain?
Patient: Not right now, no. I did have some nausea yesterday. Oh and I guess I had a slight headache when I woke up this morning, but that's about it.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: How are you? I haven't seen you in a long time.
Patient: I'm doing fine. I hurt my hand the other day.
Doctor: How did that happen?
Patient: My husband and I moved into our new home, and we were building a desk. I tried to nail something in, and I hammered my hand.
Doctor: Oh, no. So, you and your husband live together now?
Patient: Yeah. We do. We just got married.

assistant: She is married. She lives with her spouse.
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:
Patient: Man, what a night.
Doctor: What kind of car were you driving that night?
Patient: I was driving my small sports car through an intersection when another car hit me from the left side. The impact forced my car off the road and into a utility pole.
Doctor: I'm so sorry to hear that. I'm glad that you are here in one piece. Were you wearing your seatbelt?
Patient: Yeah, I had my belt on and everything.
Doctor: Good.
Patient: Unfortunately, the driver was drunk and ran a traffic signal.
Doctor: That's such a shame. Do you remember how fast the car was going when it collided into you?
Patient: If I had to guess maybe eighty miles per hour. It looks like the driver who hit me was already cited by police.
Doctor: Did you lose consciousness at all?
Patient: Yeah, I briefly lost consciousness when help arrived at the scene. I felt an immediate headache when I regained consciousness. I also had lower back and neck pain.
Doctor: Did you get out of the car by yourself?
Patient: Yeah, I got out by myself. Once I made it out, the Rescue Squad drove me to Saint Thomas Memorial Hospital. I was seen in the emergency room and later discharged.
Doctor: This was on January fifteenth, correct?
Patient: Yessir.

assistant: Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient's vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off the road into a utility pole. The other vehicle had reportedly been driven by a drunk driver and ran a traffic signal. Estimated impact speed was 80 m.p.h. The driver of the other vehicle was reportedly cited by police. The patient was transiently unconscious and came to the scene. There was immediate onset of headaches, neck and lower back pain. The patient was able to exit the vehicle and was subsequently transported by Rescue Squad to St. Thomas Memorial Hospital, evaluated in the emergency room and released.
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're you doing?
Patient: Good for the most part. I'm still pretty tired most days, but I'm trying to stay more active. I'm wondering if it has to do with my sugar levels?
Doctor: Hm let's see. I'd like to check your glucose and lipid panels and get you back in here again.
Patient: And oh I've noticed some blood in my stool. I'm not sure if it's related.
Doctor: How long has that been going on?
Patient: Maybe a week or so?
Doctor: Are you having any other symptoms? Black or tarry stool? Nausea, vomiting, diarrhea? Lightheadedness?
Patient: No, none of that.
Doctor: I'd like to order a hemoccult then. It's going to check to see if you're still having blood in your stool.
Patient: Can I do this at the blood work place?
Doctor: Yes, they'll be able to help you and answer any additional questions you may have.
Patient: Okay. I'll try to go in tomorrow.
Doctor: Remember you need to fast for the lipid panel, so I'd recommend going in early tomorrow morning before eating breakfast.
Patient: Okay, got it.
Doctor: And before I send you on your way, have you been able to schedule your yearly mammogram?
Patient: Oh shoot. I still need to do that. I'll call them tomorrow.

assistant: Significant for occasional tiredness. This is intermittent and currently not severe. She is concerned about the possibly of glucose abnormalities such diabetes. We will check a glucose, lipid profile and a Hemoccult test also and a mammogram. Her review of systems is otherwise negative.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Hello, ma'am. How are you doing?
Patient: My knees hurt. They've been slowly getting worse each year. Life's getting hard at seventy two.
Doctor: I'm sorry to hear that. Have you always had knee pain?
Patient: I have. Both knees are messed up.
Doctor: Are you able to do any activities still?
Patient: Nope. I just sit all day.
Doctor: I see. We can offer to do arthroplasty to fix your knees.
Patient: What's that?
Doctor: It's like a reconstruction of your joints. It'll help increase your ability to do daily activities.
Patient: I'm up for it. I need to get my life going.
Doctor: Sounds great. I just want to confirm some information. Would you say your quality of life and daily activities is decreasing?
Patient: Oh, yeah. These knees are making my life terrible.

assistant: The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs. She wishes to proceed with arthroplasty at this time.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: CC

Dialogue:
Doctor: How's he doing?
Guest_family: Not so great. He's been out of it. He hasn't been acting like himself.
Doctor: How long has it been since you noticed any behavioral changes?
Guest_family: A few days now.
Doctor: Is he complaining of any pain?
Guest_family: Yeah he's been-
Doctor: He's been?
Guest_family: Sorry, my phone was on vibrate and I had to turn it off.
Doctor: No problem.
Guest_family: He's been pointing to his stomach and saying it hurts.
Doctor: Is he having any other symptoms?
Guest_family: He's told me he feels queasy. I took his temperature the other night and he was running a fever of one O two.
Doctor: Any vomiting with the nausea?
Guest_family: Yeah, he's thrown up a handful of times.

assistant: Abdominal pain, nausea, vomiting, fever, altered mental status.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Good morning, sir. Remind me please, when was your surgery?
Patient: Hello, doctor. It was about a week ago now.
Doctor: Great, and just to remind you, you had a removal of Ex Fix from the right knee with an M U A following O R I F of a right tibial plateau fracture.
Patient: Yes, that all sounds familiar. What's M U A?
Doctor: It stands for manipulation under anesthesia. We bent the knee in order to forcibly break up some scar tissue.
Patient: Oh, wow.
Doctor: Yeah, it's great, eliminates some need for P T in fact. How are you doing today?
Patient: Overall, my pain is under control.
Doctor: Are you having any flu like, or infection symptoms?
Patient: No, nothing like that at all.
Doctor: So, no fever, or chills, or sweating at night.
Patient: Yeah, nothing like that.
Doctor: Great. I see you're having some drainage from the pin sites, but that doesn't bother me too much.
Patient: Okay, good. I was getting worried.
Doctor: No need to worry. Are you doing your range of motion exercises? Those are imperative.
Patient: Yes, doctor. I am.
Doctor: Good, and do you have any numbness or tingling?
Patient: No, doctor. I don't have any of that.

assistant: The patient is now approximately week status post removal of Ex-Fix from the right knee with an MUA following open reduction internal fixation of right tibial plateau fracture. The patient states that this pain is well controlled. He has had no fevers, chills or night sweats. He has had some mild drainage from his pin sites. He just started doing range of motion type exercises for his right knee. He has had no numbness or tingling.
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 just a few quick questions before we wrap up. Do you smoke or drink?
Patient: I drink sometimes. I've never smoked.
Doctor: Any drug use?
Patient: No.
Doctor: Are you sexually active?
Patient: Uh I was back in Haiti, but that was back in eighty two. I had several male partners, but no sex since moving here.
Doctor: Did you use protection in your previous encounters?
Patient: Most of the time, yes.
Doctor: Any history of S T Ds?
Patient: No.
Doctor: Are you currently working?
Patient: Yep. I work for a car dealership down the street.

assistant: He occasionally drinks and is a nonsmoker. The patient participated in homosexual activity in Haiti during 1982 which he described as "very active." Denies intravenous drug use. The patient is currently employed.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Good morning, sir, I hear you're a patient of Doctor A.
Patient: Yes, that's correct.
Doctor: Did she refer you to me?
Patient: Yeah, I'm fifty five, so I'm not too young anymore, but I have developed iron deficiency anemia with blood in my stool. At least, that's what she's told me so far.
Doctor: Are you having diarrhea?
Patient: Yeah, I am.
Doctor: How would you describe the frequency?
Patient: I'd say it's chronic at this point.
Doctor: How long have you known you have anemia?
Patient: Um, it's been a few months now.
Doctor: What markers were evaluated in order to diagnose this?
Patient: I had, um, an unusual pruritus, and I had a C B C.
Doctor: Do you have the results of that?
Patient: Yes, right here.
Doctor: Thank you, so this shows a hemoglobin of nine, and M C V of sixty five.
Patient: Are those high?
Doctor: Well, actually, both of those are low.
Patient: Oh, okay.
Doctor: How long have you had blood in your stool?
Patient: Um, it's been about five months now.
Doctor: What has the color been like?
Patient: Well, it's been both dark and bright blood, actually?
Doctor: When was your last colonoscopy?
Patient: It was about three years ago, I had it with Doctor X. I did it in Las Cruces.
Doctor: Was there any abnormality found?
Patient: Yeah, I had polyps removed.
Doctor: Were those polyps evaluated?
Patient: Yeah, the doctors said they were, um, hyperplastic. They diagnosed me with, um, lymphocytic colitis.
Doctor: I see, when was the last time you were treated for diarrhea?
Patient: At this point, it's been more than three years.

assistant: The patient is a 55-year-old gentleman, a patient of Mrs. A, who was referred to me because the patient developed iron deficiency anemia and he had blood in his stool. The patient also has chronic diarrhea. His anemia was diagnosed months ago when he presented with unusual pruritus and he got a CBC. At that time he was discovered to have hemoglobin of 9 and MCV 65. The patient also had multiple episodes of dark blood and bright blood in the stool for the last 5 months on and off. Last colonoscopy was performed by Dr. X in Las Cruces 3 years ago. At that time the patient had polyps removed from the colon, all of them were hyperplastic in nature. The patient also was diagnosed with lymphocytic colitis. He was not treated for diarrhea for more than 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: Good afternoon, before we begin, what are your pronouns?
Patient: I identify as a female, and I use she her pronouns.
Doctor: Thank you, so, have you ever had surgery?
Patient: Yes, I actually have a list of them written down.
Doctor: That's really helpful, may I see it?
Patient: Absolutely, here you go.
Doctor: Thank you. So I see you've had a multiple bowel surgeries, including, um, a hysterectomy, rectocele repair, and an appendectomy. Do all of those sound familiar.
Patient: Yep, I got this list from all of the surgeons.
Doctor: Are there any other major conditions I should be aware of?
Patient: Yes, actually, I have another list, um, I have polymyalgia rheumatica.
Doctor: That's all great information to know, thank you very much.

assistant: She has had multiple previous surgeries including bowel surgery, hysterectomy, rectocele repair, and appendectomy. She also has a diagnosis of polymyalgia rheumatica.
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 neurological disorders, such as multiple sclerosis, Parkinson's or dementia?
Patient: Nope. Fortunately, no one in my family has neurological problems.

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

user: Section: CC

Dialogue:
Doctor: How long have you had this rash?
Patient: Not long. Less than a day if I had to guess.
Doctor: Is it causing you any pain?
Patient: No, it's just really itchy. I tried applying Cortisone to it, but it didn't help much.
Doctor: Is the rash localized to the left arm?
Patient: Yeah. I've only noticed it on my left arm.

assistant: Itchy rash.