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: FAM/SOCHX

Dialogue:
Doctor: Let's talk about your family history.
Patient: Okay.
Doctor: Can you tell me about any kind of medical traits that run in your family?
Patient: I think my family has been blessed or I don't know if any.
Doctor: What about any heart disease?
Patient: Nope. No heart disease or diabetes or any other kind of issues that I'm aware of.

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: GENHX

Dialogue:
Doctor: So, how are long have you had pain in this hip?
Patient: It's been about eight or ten years now. It began while I was working in construction.
Doctor: How old are you now?
Patient: I'm thirty two now, so I've been in pain since I was in my twenties.
Doctor: Have you seen another doctor for this, or am I the first?
Patient: Yeah, um, I've actually seen several doctors before, the last I saw was Doctor A B C a few weeks ago.
Doctor: What did those doctors tell you?
Patient: They thought it was low back pain, and something called, um, radiculopathy.
Doctor: Does your pain radiate into your legs?
Patient: Yes.
Doctor: Has your pain been present for the eight years, or did it come and go?
Patient: It's been persistent, and I've had difficulties on and off since then.
Doctor: Okay. The x rays from Doctor A B C show severe degenerative changes as well as avascular necrosis of the femoral head. What else did the Doctor do for you?
Patient: He gave me some pain medicine, and we talked about going to another specialist for surgery.
Doctor: Do you remember the names of the procedures suggested?
Patient: Something about resurfacing the hip, or a hip replacement. I'm here for another opinion on that.
Doctor: I saw you come in with a cane, do you have groin pain as well?
Patient: Yes, and I can't do any of the activities I used to.
Doctor: Besides the pain medication, have you had anything else?
Patient: I've taken antibiotic steroids before.
Doctor: Okay. Do you drink?
Patient: Yes, a lot.

assistant: The patient is a 32-year-old male seen by Dr. ABC several weeks ago for persistent left hip pain. He has a long eight to ten year history of pain into the left hip. He has been worked up by several specialists and evaluated. He was thought initially to have low back pain with radiculopathy. He does have a history of antibiotic steroid use as well as heavy drinking. He reports his symptoms started approximately eight years ago when he was doing some construction at which time he began to have left hip pain. He has had difficulties on and off ever since then. On the last visit, radiographs revealed severe degenerative changes of the left hip joint with apparent AVN of the left femoral head. He was given some pain medication and discussion took place regarding referring him to a specialist for evaluation of possible hip resurfacing versus conventional total hip replacement. He came for a second opinion in the area and we discussed his problems further. He continues to have primarily groin pain, which limits his daily activities. He has used a cane in the past for a short period and he continues to have difficulty with the left hip.
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: Let me examine your skin.
Patient: Sure.
Doctor: It looks normal and well hydrated. Any excessive sweating?
Patient: No, not really.
Doctor: I don't see any injury or wounds.
Patient: Yeah.
Doctor: Its just a normal protocol to ask these questions for every new patient.
Patient: I understand.
Doctor: Thank you for your cooperation.

assistant: SKIN: Inspection within normal limits. Well hydrated. No diaphoresis. No obvious wound.
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 there! I am Doctor Kirkland.
Patient: Hi.
Doctor: How are you feeling?
Patient: I feel weird. Like I feel confused. I don't know how I got here.
Doctor: That's okay. Do you remember what happened to you before you came here?
Patient: No.
Doctor: Can you tell me about your past medical history?
Patient: Um.
Doctor: Take your time.
Patient: I can't think of what it is called. It's something to do with my brain.
Doctor: Okay.
Patient: My doctor knows what it is.
Doctor: What is the name of your doctor?
Patient: Doctor Frank.
Doctor: Doctor X? Across the street?
Patient: Yes, that is his name. I don't know if that is across the street or not.
Doctor: I will have your nurse give him a call and get some background information from him.
Patient: Okay.
Doctor: Can you please give Doctor X a call and get mister Jones' medical history?
Guest_clinician: Yes, of course.
Doctor: Thank you.

assistant: The patient himself is not able to give a good history. History has obtained through discussion with Dr. X over the phone and the nurse taking care of the patient despite reviewing the chart on the floor.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: And are you working? What do you do?
Patient: Oh, I am a catholic priest!
Doctor: Oh wow!
Patient: Yes.
Doctor: And if you don't mind me asking, do you drink alcohol?
Patient: Maybe that is something for my confession box but jokes apart I don't drink.
Doctor: Sorry I need to ask these questions it's a protocol.
Patient: I understand.
Doctor: And can I put down here that you don't smoke or use any kinds of drugs?
Patient: Yes, I don't do those either.
Doctor: Cool.

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

user: Section: ASSESSMENT

Dialogue:
Doctor: So, he is Arjun, and he is thirty seven years old and was complaining of chest pain.
Patient: Hi Doctors, how are you?
Doctor: We are good thanks for asking.
Guest_clinician: Hi there Arjun, I am doctor J and I am assisting Doctor Wilson today. So, chest pain huh?
Patient: Yep.
Guest_clinician: And I see here no cardiac excretion was mentioned.
Doctor: Yeah. I am suspecting coronary spasm but that's questionable.
Guest_clinician: Okay.
Doctor: I did run a cardiac enzyme profile and it was negative.
Guest_clinician: Alright. And he also has hyperlipidemia?
Doctor: Yes, he does.
Guest_clinician: Okay and did you order an E K G?
Doctor: I did, it is normal too.
Guest_clinician: Don't worry Arjun, we will take of you.
Patient: Thank you.

assistant: 1. Chest pain in a 37-year-old gentleman with negative cardiac workup, questionably right coronary spasm. 2. Hyperlipidemia. 3. Negative EKG and cardiac enzyme profile.
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 live in the area?
Patient: Yes, my husband and I have lived here for a long time. He died a few years back.
Doctor: I'm sorry to hear that.
Patient: It's alright.
Doctor: Do you smoke or drink?
Patient: No, I don't.
Doctor: Do you use any illicit drugs or substances?
Patient: No, I don't do anything like that.

assistant: The patient lives locally. She is a widow. She does not smoke cigarettes or use illicit drugs.
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: Um, I take the generic for Ultracet. Sometimes I take as many as four times a day.
Doctor: Does this help the pain?
Patient: No, I'm still in pretty significant pain, doctor.

Doctor: Good morning, sir. My nurse's chart says that you're thirty four years old. Is that correct?
Patient: Yes, doctor, that's correct.
Doctor: How long have you had this back pain?
Patient: Well, it's been a while now.
Doctor: Does the pain go into your legs?
Patient: Yes, into the left leg, more towards the outside of my leg.
Doctor: Is there any injury that started this pain?
Patient: Yeah, I was lifting at work on August twenty seventh two thousand three when I lifted something and felt a pretty sharp pain from my back down into my left leg.
Doctor: Have you had back pain or surgeries before this injury?
Patient: No, I haven't.
Doctor: Are you having weakness in the legs?
Patient: Yes, I am.
Doctor: Okay, I believe you are a good candidate for surgery, sir. It seems like you have a lot of weakness and pain in the S one nerve root distribution.
Patient: Okay. What are the risks of infection for this surgery?
Doctor: Overall, the risk of infection is very low, less than one percent. We use antibiotics to control for infection the entire time.
Patient: Will I be asleep for the surgery?
Doctor: Yes, you'll be under anesthesia. You won't feel a thing.
Patient: Okay, yes. I'd like to do the surgery.

assistant: This is a 34-year-old male with history of back pain with radiation into the left leg in the S1 nerve root distribution. The patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity. He denied any previous history of back pain or back surgeries. Because of his intractable pain as well as severe weakness in the S1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on. After an informed consent was obtained, all risks as well as complications were discussed with the patient.
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: Mister Sunil, your blood pressure is high, and I am noticing this from past two-three times you have been here. It's been constantly high, you are not taking it seriously.
Patient: No, nothing like that Doctor! It's been well under control. I have been monitoring at home.
Doctor: Are you noting your readings? Did you bring it with you?
Patient: No. I did not get the readings with me but I assure you I am taking care and my B P is normal.
Doctor: Well, it's up and I am little bothered by it.

assistant: His blood pressure up. The last two to three times he has been in here, it has been up. He has assured me before that his blood pressure is under good control at home, but he does not bring any blood pressures in with him this time, which bothers me.
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 dad had colon cancer.
Doctor: Did your dad pass from colon cancer?
Patient: No. They caught it early. He passed away from old age. My mom passed away when she was in her nineties from a stroke.
Doctor: I am sorry. Do you have any family history of any neurological disorders like, M S, Alzheimer's, Parkinson's or epilepsy?
Patient: Other then my mom having a stroke, I know of nothing else.

assistant: His mother died of a stroke in her 90s. His father had colon cancer. 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: PASTMEDICALHX

Dialogue:
Doctor: Hello. I see you're here for a follow up. Did you get your blood work done?
Patient: I did. Here are the results.
Doctor: Let me take a look. Oh, wow. It looks like your blood sugar is high. Are you exercising every day?
Patient: Not really. Is that bad?
Doctor: You are at risk of developing type two diabetes.

assistant: Adult-onset 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: PASTSURGICAL

Dialogue:
Doctor: Have you had ever had surgery?
Patient: Yeah, I had my gallbladder removed a few years ago.
Doctor: Thank you, what about any other parts of the body, like your eyes, ears, or nose?
Patient: Oh yeah, I forgot. I had eye surgery too.
Doctor: Thank you, think hard, any other surgeries you can remember?
Patient: Let me look at my notes, um, it looks like I had a dilation and curettage done some time back, too.
Doctor: I see. Thank you for sharing that with me.

assistant: Cholecystectomy, eye surgery, D&C.
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 there! How are you doing?
Patient: Um. I am feeing really strange.
Doctor: Strange how?
Patient: I took Ecstasy over the weekend and I feel weird still. My heart is racing. I feel agitated and have been having waves of sadness. I cannot shake this feeling.
Doctor: When did you take the Ecstasy?
Patient: On Saturday.

assistant: "I took Ecstasy."
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 live alone?
Patient: I do. I lost my husband to prostate cancer last year.
Doctor: Oh wow. I'm so deeply sorry for your loss. Losing a loved one is incredibly difficult. I lost my sister to cervical cancer two years ago. It was one of the hardest experiences of my life.
Patient: I'm sorry for your loss as well. It helps to remember the positive memories you had with them.
Doctor: Yes, definitely. How have you been doing otherwise?
Patient: Not bad. I've been keeping myself busy with gardening.
Doctor: Gardening is a great hobby.
Patient: Yes, I enjoy it very much. It brings me a lot of peace.
Doctor: And as your doctor I have to ask, but any history of alcohol or drug use?
Patient: No.

assistant: She is a widow, lives alone. Denies any tobacco or alcohol 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: FAM/SOCHX

Dialogue:
Doctor: Hello. How are you doing today?
Patient: I feel depressed.
Doctor: I'm sorry to hear that. What's been happening?
Patient: My parents were fighting for a long time, and I think they're not together anymore.
Doctor: That must be really hard. I'm sorry to hear that they're divorced. Who do you live with right now?
Patient: I usually hop houses. I'll go to my dad's house the first half of the week and spend time with his family. Then, I'll go to my mom's house during the last half of the week.
Doctor: That's nice. Now you can ask for more gifts during Christmas.
Patient: You know what? I never thought about that. That's a really good idea.

assistant: The patient's parents continued to undergo a separation and divorce. The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the 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: FAM/SOCHX

Dialogue:
Doctor: What do you do for a living?
Patient: I'm a real estate agent.
Doctor: How long have you been working in the real estate business?
Patient: Almost twenty years.
Doctor: Wow. I know who to go to when I'm looking to buy a house.
Patient: Happy to help.
Doctor: So let's see here. Do you drink or smoke?
Patient: I drink socially, but it's very infrequent.
Doctor: And I have to ask, but any drug use?
Patient: Nope. Not now, not ever.

assistant: No tobacco use, occasional EtOH, no known drug use, works as a real estate agent.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Welcome back in, Miss A.
Patient: Thank you, doctor.
Doctor: Do you remember the information about your operation?
Patient: No, not really. Can you remind me?
Doctor: Sure, you had a lap band replacement in January of O nine, and you had a band adjustment.
Patient: Thank you.
Doctor: How are you feeling today?
Patient: Well, I've been under a lot of stress lately, and I had problems with my adjustments before.
Doctor: Has anything changed since the operation?
Patient: Actually, doctor, I was in a car accident a couple weeks ago, and I'm having problems.
Doctor: What symptoms are you experiencing?
Patient: I don't feel full.
Doctor: How is your appetite?
Patient: I'm not really hungry, but I also don't feel full. When I get hungry at night I can't wait until the morning to eat. I get so hungry.
Doctor: Do you eat anything when you feel like this?
Patient: Yeah, I usually have a candy bar, and that helps some.

assistant: Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment. Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress. She was in a car accident a couple of weeks ago and she has problems, she does not feel full. She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.
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, where do you live?
Patient: Ah, I now live in an assisted nursing facility.
Doctor: Okay, and do you drink or smoke?
Patient: No, neither.

assistant: She is a nondrinker and nonsmoker and currently lives at the skilled nursing facility.
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 specific medical traits in the family?
Patient: What do you mean by that?
Doctor: I meant does anyone in your family or extended family have any medical problems that they were treated for?
Patient: I'm not aware of any such thing in my family.

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: Welcome in! I am Doctor Madison.
Patient: Thank you. It's nice to meet you.
Doctor: Are you married?
Patient: Yes. We just got hitched last year.
Doctor: Congratulations!
Patient: Thank you.
Doctor: Do you drink alcohol?
Patient: No, I don't drink.
Doctor: Do you smoke cigarettes?
Patient: Yes. I know it's bad for me.
Doctor: How much do you smoke per day?
Patient: About a pack a day.
Doctor: Okay. I have a lot of tools to help you quit smoking that we can discuss.
Patient: Okay.

assistant: Marital status: Married. The patient smokes 1 pack of cigarettes per day. Denies use of alcohol.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PLAN

Dialogue:
Doctor: We have you scheduled for a follow up and to have the staples removed in one week with Doctor X Y Z. Do you have your wound care instructions?
Patient: Yes.
Doctor: Do you have any questions?
Patient: No.
Doctor: If you do have questions or concerns that may come up, please don't hesitate to call the office.
Patient: Okay.
Doctor: If you develop a fever greater than one hundred and one point four, chills, nausea, vomiting, or continuing diarrhea please call the office. Also if your incision site becomes red, warm to the touch or has any drainage, call the office.
Patient: Okay.

assistant: The patient was instructed to contact us with any questions or concerns that may arise. In addition, he was instructed to contact us, if he would have fevers greater than 101.4, chills, nausea or vomitting, continuing diarrhea, redness, drainage, or warmth around his incision site. He will be seen in about one week's time in Dr. XYZ's clinic and his staples will be removed at that 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: ASSESSMENT

Dialogue:
Doctor: Have you had sinus issues before?
Patient: I am not sure, maybe on and off.
Doctor: Because this is more allergic.
Patient: Okay.
Doctor: So, we call it allergic rhinitis.
Patient: Is it different than sinus infection?
Doctor: Yes, it's it is different.
Patient: Okay.

assistant: I think this is still his allergic rhinitis rather than a sinus infection.
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: She has a rare case of thrombocytopenia. I'd like her to come in for a consult.
Guest_clinician: Any other medical history?
Doctor: No, just the thrombocytopenia.

assistant: Thrombocytopenia.
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 there how are you?
Patient: I am good no problem at all other than the usual.
Doctor: And what is that?
Patient: You know, some discomfort I have on my right side. I have been feeling that since I had a stroke five years back.
Doctor: Right, right. We did an E M G right?
Patient: Yes.
Doctor: And none of the medications we tried are helping?
Patient: No, I also saw a neurologist, but nothing is helping
Doctor: Okay, and are you monitoring your sugar regularly?
Patient: Oh yes, Everyday at least two to three times a day.
Doctor: And how bout insulin dose?
Patient: Oh, that I kind of adjust myself.
Doctor: Well, I have rechecked all the symptoms and everything looks fine. I don't see anything out of order, but we will keep monitoring.
Patient: Okay.
Doctor: And you are not smoking or drinking again are you?
Patient: No, not since I had the stroke.
Doctor: In the past you had a history of heavy usage of both alcohol and smoking, you need to be careful. You are seventy years old.
Patient: Yeah, I am taking care of it.
Doctor: Alright take care then.

assistant: This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see a neurologist. We have tried different medications and it just does not seem to help. He checks his blood sugars at home two to three times a day. He kind of adjusts his own insulin himself. Re-evaluation of symptoms is essentially negative. He has a past history of heavy tobacco and alcohol usage.
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 is the strength of your Omeprazole?
Patient: It is forty M G and I take it just once a day.
Doctor: Any herbal medication?
Patient: No I do not take anything like that.

assistant: Omeprazole 40 mg once a day. Denies herbal medications.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: So, to double check, you have a history of hay fever and asthma, correct?
Patient: Yes. I was also recently diagnosed with cervical dysplasia. I found out shortly after my last O B G Y N visit.
Doctor: And are you planning to follow up with your O B G Y N in the upcoming months?
Patient: Yeah, the next visit is scheduled and everything.

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: FAM/SOCHX

Dialogue:
Doctor: So, do you have any family history of arthritis?
Patient: Fortunately, no, not that I know of.
Doctor: So, as far as you know, no one has had a joint replacement?
Patient: No, it doesn't ring any bells.

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

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Please, tell me about your medical history.
Patient: I've been dealing with depression and anxiety for some time now.
Doctor: I'm sorry, that must be difficult.
Patient: Thank you, it is, but I manage.
Doctor: What about your joints? How do you move?
Patient: Oh yes, I have arthritis as well. I also had sciatic pain a long time ago, and a herniated disk.
Doctor: Have you ever had neurological symptoms, like headaches, blurry vision, or weakness?
Patient: Actually yes, I have migraines when I'm having my period.
Doctor: Thank you, and have you had any surgery in the past?
Patient: Yes, I had my appendix out.

assistant: Anxiety, depression, osteoarthritis, migraine headaches associated with menstrual cycle, history of sciatic pain in the distant past, history of herniated disc, and status post appendectomy.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Do you have any past history of psychiatric treatment of struggles?
Patient: I had some extreme fatigue back in nineteen ninety one. I was in therapy for six years. They had me on Prozac. I took in for that whole six years while I was in therapy. When I started the Prozac, I had just started working again. The stress at work was overwhelming.
Doctor: Was this the first time that you had feelings for fatigue and depression?
Patient: No. I have always had a little sadness or depressed time in my life but it had been manageable before all the work stress started happening.
Doctor: How are you feeling these days?
Patient: I get somewhat sad from time to time but I don't dwell on things anymore.
Doctor: Do you ever have thoughts of selfharm or suicidal thoughts?
Patient: No.

assistant: The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue. She was also taking Prozac during that time. She then began taking Prozac again when she started working at secondary to stress with the work situation. She reported a chronic history of mild sadness or depression, which was relatively stable. When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things. She denied any history of suicidal ideation or homicidal ideation.
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 other children do you have?
Guest_family: My husband and I have three children, your patient today, and another boy, and girl.
Doctor: How is everyone else doing?
Guest_family: They're all doing very well, thank you for asking.
Doctor: Do you live here in Easton?
Guest_family: Yes, born and raised.
Doctor: Good, do you have any pets?
Guest_family: We have four dogs, three cats, and three mules.
Doctor: What, no deer?
Guest_family: No, no deer, at least not anymore.
Doctor: What grade are you in, young man?
Patient: I'm in the second grade, doctor.
Doctor: Good, how do you like P E? Are you able to play no problem?
Patient: Yes, I love P E. I don't have any problems there.

assistant: He lives with mom, dad, brother, sister, and everybody is healthy. They live in Easton. They have 4 dogs, 3 cats, 3 mules and no deer. At school, he is in second grade and he is doing PE without any limitation.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PLAN

Dialogue:
Doctor: Are you still doing water aerobics?
Patient: Yeah, I've been hitting the pool five days outta the week.
Doctor: How're you feeling? Have you noticed any changes in energy and strength?
Patient: I feel a bit stronger now compared to when I first started. I'm also way, way more energized.

assistant: As tolerated. Continue water exercise five days 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: GENHX

Dialogue:
Doctor: Do you have any history of chronic pain?
Patient: I got into a car accident a long time ago and I have always had neck pain.
Doctor: Okay. Any other pain throughout the body?
Patient: Sometimes I have back pain.
Doctor: Okay.

assistant: Back and neck 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: IMAGING

Dialogue:
Doctor: I have reviewed your x rays from your emergency room visit. I agree with Doctor Jones that your lungs show no signs of infection or decreased lung capacity.
Patient: Okay.

assistant: Chest x-ray ordered by ER physician is unremarkable, but to me also.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Hello, how are you doing? What brings you here?
Patient: I think I have allergies. I used to live in Seattle. I had allergies there, but I think they're getting worse after moving here. You see, I'm twenty three and I am a white female. I was in Seattle, I thought that the weather there is not for me. That's why I plan to move on here, but my allergies are not leaving me here either.
Doctor: What did you take for your allergies before?
Patient: Claritin and Zyrtec.
Doctor: How effective were they?
Patient: They seemed to be working for some time, but now I feel like nothing is effective anymore.
Doctor: Have you ever tried Allegra?
Patient: Yes, I tried that last summer and I've started it again like two weeks ago. But again, the story is the same. They work for some time and now it doesn't seem to be working anymore.
Doctor: Have you tried sprays?
Patient: I did use some over the counter ones. But I never got any prescribed nasal spray.
Doctor: Any other medically related history that I should be aware of?
Patient: I do have asthma if that counts.
Doctor: Are you taking any medications for your asthma?
Patient: Nope, nothing on the regular basis.
Doctor: Do you think it is your asthma that is flaring up?
Patient: I don't think so. I think, I still think it is just some allergies. I want to get tested.

assistant: This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here. In the past, she has tried Claritin, and Zyrtec. Both worked for short time but then seemed to lose effectiveness. She has used Allegra also. She used that last summer and she began using it again two weeks ago. It does not appear to be working very well. She has used over-the-counter sprays but no prescription nasal sprays. She does have asthma but doest not require daily medication for this and does not think it is flaring up.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Good afternoon, ma'am.
Patient: Good afternoon doctor.
Doctor: So, do you have any medical conditions I should know about.
Patient: Actually, yes. I have a few. I have hyperthyroidism, and I've had gallbladder issues for some time now.
Doctor: I see. How's your blood pressure?
Patient: Oh, um, I have high blood pressure too.

assistant: The patient has a history of multiple medical problems including hypothyroidism, hypertension, and gallbladder difficulties.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are you a smoker, sir?
Patient: Yes, I've been smoking about a pack, to about a pack and a half a day for more than forty years now.
Doctor: What about alcohol, do you drink?
Patient: Yeah, I drink a six pack of beer a day, doctor.
Doctor: What about drugs? Do you use any illicit substances?
Patient: No, I never used anything like that.

assistant: The patient smoked 1-1/2 packs for more than 40 years. He consumes 6 beers per day. He denies any 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: DIAGNOSIS

Dialogue:
Doctor: I'd like her to come see you for a consult tomorrow.
Guest_clinician: How long has she been suffering from migraines with aura?
Doctor: About five years now.
Guest_clinician: Does she have a neurologist she sees regularly?
Doctor: Not since moving here.

assistant: Migraine with aura.
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, sir, are you married?
Patient: Yes, I'm married to my lovely wife.
Doctor: That's great, so, what did you do for a living?
Patient: I was a Pepsi Cola truck driver, but thankfully, I'm retired.
Doctor: Congratulations on your retirement. What seems to be the problem today then?
Patient: Thank you, it's nice to be done with that. The years took their toll though, I have a lot of pain in my back and knees.
Doctor: Ah, yes, those years of sitting and lifting eventually catch up to everyone.

assistant: Married. He is retired, being a Pepsi-Cola driver secondary to his back and knees.
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 about your family medical history.
Patient: The only thing that I know about is that my grandma has diabetes.

assistant: Positive for diabetes mellitus in the maternal grandmother.
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: Hello, Mister G, how are you today?
Patient: I am good doctor thank you for asking. I am here to talk to you about my will.
Doctor: Yeah, nurse informed me. So, tell me how can I help you?
Patient: As you know I have terminal cancer. I have decided I do not want to be resuscitated. I have appointed my daughter as my legal healthcare proxy and she respects my wish.
Doctor: Tell me what I can do to make you comfortable?
Patient: Honestly doctor you have done enough and I am so thankful for that. I just wish to spend my last days at home surrounded with loved ones. I have my nurse, she takes care of me. I think I am fine!
Doctor: Alright my friend.

assistant: CODE STATUS: Do not resuscitate, healthcare proxy, palliative care orders in place.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you smoke?
Patient: Nope.
Doctor: What about alcohol? Or any kind of drugs?
Patient: Nope.

assistant: No smoking or drinking. No drugs.
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: History of any illnesses, surgeries, or hospitalizations?
Patient: I dislocated my wrist when I was a kid but that's all.

assistant: Surgeries: None. Injuries: Dislocated wrist. Illnesses: 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: ROS

Dialogue:
Doctor: Any pain while peeing?
Patient: No.
Doctor: Any change in frequency or feeling the urgency to pee?
Patient: No.
Doctor: And what about bladder control, any accidents?
Patient: No.
Doctor: Any history of syphilis or any other S T D?
Patient: No, never.
Doctor: Okay.

assistant: GENITOURINARY: Negative frequency, negative urgency, negative dysuria, negative incontinence. No history of STDs.
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: Is there any history of heart disease in your family?
Patient: Yes, my dad and brother had heart vessel blockage type of disease in their forties.

assistant: Positive for coronary artery disease in her father and brother in their 40s.
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: If I'm understanding correctly, you sustained an elbow injury during a fight with some other kids in Juvenile Hall?
Patient: Yeah. My left elbow is killing me.
Doctor: How old are you?
Patient: Seventeen.
Doctor: Are you having pain anywhere else?
Patient: Yeah. My left ankle also hurts.
Doctor: Are you able to walk without difficulty?
Patient: Yeah.
Doctor: Any knee pain?
Patient: Not right now, but I've had left knee pain in the past.
Doctor: Did you pass out or hurt your neck in any way?
Patient: I didn't pass out. I hit my head against the floor when one of the kids tried to pin me down.
Doctor: Do you have a headache, nausea, or blurry vision?
Patient: No.
Doctor: And no chest or abdominal pain?
Patient: No.
Doctor: Were there any weapons like knives or guns used during the fight?
Patient: No.

assistant: This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain. He also has pain in his left ankle, but he is able to walk normally. He has had previous pain in his left knee. He denies any passing out, any neck pain at this time even though he did get hit in the head. He has no chest or abdominal pain. Apparently, no knives or guns were involved.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Hello. Before we begin your visit, I noticed some information missing. Could I verify the information with you?
Patient: Of course.
Doctor: Does your family have a history of any health related problems?
Patient: Oh, yeah. A lot of my family have heart problems and cancer.
Doctor: I see. Do you know what kind of cancer?
Patient: I'm not completely sure, but my wife may know. She's here with me right now.
Doctor: Great. I'll bring her in.
Guest_family. Hello. I'm his wife.
Doctor: Do you know what type of cancer runs in his family?
Guest_family: I do. I believe it's carcinoma.
Doctor: Thank you. Sir, are there any other health related problems I should be aware of?
Patient: High blood pressure and food allergies run in my family too.

assistant: Strong for heart disease, carcinoma, and a history of food allergies, and there is also a history of hypertension.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: What do you do for living?
Patient: I am an officer at United States Marine office, artillery repair specialist.
Doctor: Do you drink alcohol?
Patient: I use to drink socially but stopped two years back.
Doctor: How about smoking and drugs?
Patient: No not that.

assistant: He is employed as a United States Marine officer, artillery repair specialist. He was a social drinker in the past but quit altogether two years ago. He never used tobacco products or illicit/intravenous drugs.
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 are you today?
Patient: I am good.
Doctor: What is your past medical history?
Patient: I don't have any health problems. Not yet at least.
Doctor: Let's keep try to keep it that way.
Patient: Yes please.

assistant: Essentially 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: LABS

Dialogue:
Doctor: Well, I am looking at your ultrasound report and honestly the only significant finding of this area is that it shows to be related to bone.
Patient: Oh okay.

assistant: The only significant finding in the ultrasound of the area is that it shows this to be related to bone.
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 about your family. Did anyone have any medical issues?
Patient: My father is alive. He is sixty nine right now. He did have some strokes in the past. My mom on the other hand died at the age of sixty two of many kinds of heart diseases.
Doctor: What about your grandparents?
Patient: My maternal grandfather he also had heart issues and he died of a heart attack. Both he and my maternal grandma had some heart diseases. Their heart use to beat pretty fast.

assistant: Father alive age 69 with h/o TIAs. Mother died age 62 and had CHF, A-Fib, CAD. Maternal Grandfather died of an MI and had h/o SVT. Maternal Grandmother had h/o SVT.