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: What brings you back into the clinic today, miss?
Patient: I came in for a refill of my blood pressure medicine.
Doctor: It looks like Doctor Kumar followed up with you last time regarding your hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones. Have you noticed any changes or do you have any concerns regarding these issues?
Patient: No.
Doctor: Have you had any fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure?
Patient: No.
Doctor: Great. Also, for our records, how old are you and what race do you identify yourself as?
Patient: I am seventy six years old and identify as a white female.

assistant: The patient is a 76-year-old white female who presents to the clinic today originally for hypertension and a med check. She has a history of hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones. Since her last visit she has been followed by Dr. Kumar. Those issues are stable. She has had no fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure.
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're you feeling today?
Patient: Terrible. I'm having the worst headache of my life.
Doctor: I'm so sorry. Well you are only twenty five, so let's hope this is the last of the worst. Let's see how we can best help you. When did it start?
Patient: Around eleven in the morning.
Doctor: Today?
Patient: Um no yesterday. July thirty first.
Doctor: July thirty first O eight. Got it. Did it come on suddenly?
Patient: Yeah.
Doctor: Are you having any symptoms with it, such as blurry vision, light sensitivity, dizziness, lightheadedness, or nausea?
Patient: I'm having blurry vision and lightheadedness. I also can't seem to write well. It looks so messy. I am naturally right handed but my writing looks like I am trying with my left.
Doctor: How would you describe the lightheadedness?
Patient: Like there are blind spots.
Doctor: Okay. How about any vomiting?
Patient: Um no. I feel like my face is pretty swollen though. I don't know if it's related to the headache but it started around the same time.
Doctor: Here in the E R, we'll do a thorough exam and eval to make sure nothing serious is going on. While we're waiting for your C T results, I'm going to order a migraine cocktail and some Morphine.
Patient: Thank. Will the nurse be in soon?
Doctor: Yes, she'll be right in as soon as the order is placed. It shouldn't be more than a few minutes. If it takes longer, then please ring the call bell.

assistant: The patient is a 25-year-old right-handed Caucasian female who presented to the emergency department with sudden onset of headache occurring at approximately 11 a.m. on the morning of the July 31, 2008. She described the headache as worse in her life and it was also accompanied by blurry vision and scotoma. The patient also perceived some swelling in her face. Once in the Emergency Department, the patient underwent a very thorough evaluation and examination. She was given the migraine cocktail. Also was given morphine a total of 8 mg while in the Emergency Department. For full details on the history of present illness, please see the previous history and physical.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Hello, miss. What is the reason for your visit today?
Patient: I think I have some warts on my back end where the poop comes out.
Doctor: I see. When did you start noticing them?
Patient: I think like three to four weeks ago.
Doctor: Do you feel any pain or discomfort?
Patient: It itches a little, but I haven't felt any pain yet. Is this normal for a twenty two year old?
Doctor: I'll have to take a look, but you'll be fine. Are there any other symptoms that you are aware of?
Patient: Nope. Just the warts and itchiness.

assistant: This is a 22-year-old female, who presented to the office complaining of condylomas she had noted in her anal region. She has noticed approximately three to four weeks ago. She denies any pain but does state that there is some itching. No other symptoms associated.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: MEDICATIONS

Dialogue:
Doctor: Are you taking any over the counter medicines?
Patient: No, only the ones which were prescribed.
Doctor: No alternative medicine, naturopathy or anything?
Patient: No, only whatever is here in this prescription.
Doctor: Okay let me take a look...so you were prescribed Salmeterol inhaler-
Patient: On as needed basis.
Doctor: Okay and the other one is Fluticasone inhaler, which is-
Patient: Which is a nasal inhaler.
Doctor: Right.

assistant: Prescribed medications were Salmeterol inhaler, prn; and Fluticasone nasal inhaler. The patient was taking no over the counter or alternative medicines.
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, how are you?
Patient: I burned my hand.
Doctor: Oh, I am sorry. Wow!
Patient: Yeah.
Doctor: Is it only right arm?
Patient: Yes.

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

user: Section: PASTMEDICALHX

Dialogue:
Doctor: How's your asthma since you started using your inhaler again?
Patient: Much better. I don't know why I didn't take it with me everywhere I went.
Doctor: It's important to carry it with you, especially during times where you're exercising or walking more than usual.
Patient: Yeah. I think I've learned my lesson.
Doctor: Besides asthma, do you have any other medical problems?

assistant: Asthma.
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 smoke?
Patient: No, I quit before I had my daughter.
Doctor: Are you currently pregnant?
Patient: No, I'm not.
Doctor: Did you have any complications with the birth of your daughter?
Patient: I actually had a C section.
Doctor: Have you had any other surgeries in the past?
Patient: I got my appendix out a few years ago.
Doctor: Do you have any other issues, like high blood pressure or heart disease?
Patient: No.
Doctor: Do you have diabetes?
Patient: No.
Doctor: Are there any problems with the lungs, thyroid, kidney, or bladder?
Patient: No.
Doctor: So, how long ago did you hurt your lower back?
Patient: It was about four or five years ago now, when I was in a car crash.
Doctor: What kind of treatments were recommended?
Patient: They didn't recommend P T, and I didn't really have any increased back pain after the accident.

assistant: The patient denies high blood pressure, diabetes, heart disease, lung disease, thyroid, kidney, or bladder dysfunctions. The patient stated that she quit smoking prior to her past childbirth and is currently not pregnant. The patient has had a C-section and also an appendectomy. The patient was involved in a motor vehicle accident four to five years ago and at that time, the patient did not require any physical therapy nor did she report any complaints of increased back pain following that accident.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Hi there, sir! How are you today?
Patient: Hello! I am good.
Doctor: I would like to start with your family medical history today. What do you know about their medical history?
Patient: My mother and father both had heart disease. Well, my mother had complication from her heart disease and that is how she passed. My father was only in his forty's when he died.
Doctor: I am so sorry the hear that.
Patient: Thank you. I have two brothers, one whom I don't speak to very much anymore. I don't know if he has any health problems. My other brother is healthy with no issues. Both my uncles on my mother's side had polio, I think.
Doctor: Tell me more about your uncles with polio. They both had polio?
Patient: One of them had to wear crutches due to how bad his leg deformans were and then the other had leg deformities in only one leg. I am fairly certain that they had polio.
Doctor: Do you know of any other family member with neurological conditions?
Patient: No. None that I know of.
Doctor: Do you have any children?
Patient: Yes. I have one child.
Doctor: Is your child healthy and well?
Patient: Yes.

assistant: His mother died of complications from heart disease. His father died of heart disease in his 40s. He has two living brothers. One of them he does not speak too much with and does not know about his medical history. The other is apparently healthy. He has one healthy child. His maternal uncles apparently had polio. When I asked him to tell me further details about this, he states that one of them had to wear crutches due to severe leg deformans and then the other had leg deformities in only one leg. He is fairly certain that they had polio. He is unaware of any other family members with neurological conditions.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Can you tell me about any diseases that run in your family?
Patient: Sure, my brother has a prostate cancer.
Doctor: Okay, brother.
Patient: My father had brain cancer.
Doctor: Okay, dad.
Patient: Then on both sides of my family there are many heart related issues.
Doctor: Okay.
Patient: And my brother and sister both have diabetes.
Doctor: Okay.
Patient: Yes, that's it.

assistant: His brothers had prostate cancer. Father had brain cancer. Heart disease in both sides of the family. Has diabetes in his brother and sister.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Good afternoon, ma'am. Welcome to A B C D General Hospital. Before we begin, I just need to confirm some background information on you.
Patient: Good afternoon, doctor. Absolutely, that's no problem.
Doctor: First, how old are you?
Patient: I'm nineteen, sir.
Doctor: Good, and your chart says you identify as Caucasian. Is that correct?
Patient: Yes, sir, that's correct.
Doctor: Great, what seems to be problem today, ma'am?
Patient: I've had this bunion on my foot for such a long time.
Doctor: How long has this bunion been present?
Patient: At this point, um, I don't even remember how long it's been.
Doctor: Do you have any other conditions that I should be aware of?
Patient: Actually, yes. I have a history of, um, Charcot Marie tooth disease.
Doctor: That's good to know, thank you.
Patient: I would like to have surgery to cut this bunion off, I can't take it anymore.

assistant: This 19-year-old Caucasian female presents to ABCD General Hospital. The patient states she has had worsening bunion deformity for as long as she could not remember. She does have a history of Charcot-Marie tooth disease and desires surgical treatment 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: MEDICATIONS

Dialogue:
Doctor: Are you talking any medications?
Patient: No, I don't believe in meds.
Doctor: Oh really, let me check your list.
Patient: Yeah never.
Doctor: Wow amazing.

assistant: 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: PASTMEDICALHX

Dialogue:
Doctor: Any past medical history?
Guest_family: She has a history of peptic ulcer disease and we think she may have had a possible stroke three or four years ago. I would have to double check.
Doctor: Let me see if I can find it in her records.
Doctor: Does she see a neurologist?
Guest_family: Um I'm not sure. I can call her son?
Doctor: Yes, if you could find out that'd be great.
Guest_family: She's also experiencing some memory loss as of one to two years ago. I think that's it for medical history.

assistant: PUD, ?stroke and memory difficulty in the past 1-2 years.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: How old are you?
Patient: I am forty four.
Doctor: Are you right handed or left handed?
Patient: I'm right handed.
Doctor: Tell me what happened.
Patient: I don't know. I woke up over this numbness on my left side of the body. I remember it was on July twenty nineth.
Doctor: Was there any sensation like having pins and needles? Was there any weakness? Is there any change in your visual or mental status? Were you able to walk?
Patient: I was able to walk and there was no weakness or any other thing you mentioned.
Doctor: When did you first start noticing these symptoms?
Patient: There was nothing around Independence Day. It all started after that. At first, I felt that my right hand is very clumsy, and it is kind of stiff. Then I noticed leaning towards the right when walking. It was strange. Happened around July seventh.
Doctor: Did you recently have any cold or flu like symptoms?
Patient: No.
Doctor: Were diagnosed with a thing called multiple sclerosis?
Patient: No.
Doctor: Did you ever have a feeling where you felt like there's an electric is going up or down your spine?
Patient: No.
Doctor: How about any fatigue or pain? Any frequency in your urination? Any urgency in that?
Patient: No.

assistant: This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when walking. She denied any recent colds/flu-like illness or history of multiple sclerosis. She denied symptoms of Lhermitte's or Uhthoff's phenomena.
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: You had a heart surgery, right?
Patient: Yes, that is right.
Doctor: Pacemaker?
Patient: Yes, they did that.
Doctor: What else? What other surgeries?
Patient: I have had a hysterectomy.
Doctor: Okay.
Patient: Yeah.

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

user: Section: GENHX

Dialogue:
Doctor: How old are you, young boy?
Patient: I am twenty nine.
Doctor: And you got right side shoulder pain? Is this something new?
Patient: Yes. That is right.
Doctor: What were you doing when this happened?
Patient: I think I was picking up a stack of cardboard, then putting it down on the ground and twisting to the right side. And sometimes I was throwing them a little bit as well.
Doctor: Okay, and how far you were lifting them or bending?
Patient: Around here, till waist level.
Doctor: Okay.
Patient: I heard a pop and since then there is pain in this area. I can't lift heavy items. Basically I have no strength.
Doctor: Okay. And this all started from June thirty two thousand and four?
Patient: Yes, that's right. The pain is in the lateral part of the back of my shoulder.
Doctor: How did you lose your arm if I may ask?
Patient: Motorcycle accident.

assistant: This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain. He states that this began approximately one week ago when he was lifting stacks of cardboard. The motion that he describes is essentially picking up a stack of cardboard at his waist level, twisting to the right and delivering it at approximately waist level. Sometimes he has to throw the stacks a little bit as well. He states he felt a popping sensation on 06/30/04. Since that time, he has had persistent shoulder pain with lifting activities. He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder. He has no upper extremity .
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: When did the nausea and vomiting start?
Patient: About a few hours ago. I can't seem to stomach anything.
Doctor: How many episodes of vomiting have you had?
Patient: At least four.
Doctor: Any abdominal pain, fever, chill, or other symptoms?
Patient: Just nausea and vomiting. It's been so terrible.
Doctor: I'll order you some Zofran to help bring the nausea to bay. One moment while I put the order in.

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

user: Section: GENHX

Dialogue:
Doctor: Good afternoon, ma'am.
Patient: Good afternoon, doctor.
Doctor: Is this your assistant, ma'am?
Patient: Yes, she helps me out all day.
Doctor: Great, do you have your food diary sheets?
Patient: Yes, can you give them to her, please?
Doctor: Thank you. What are you doing for exercise?
Patient: Um, right now, I walk around at the mall to get my steps in every day.

assistant: The patient's assistant brings in her food diary sheets. The patient says she stays active by walking at the mall.
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, sir. I see your last visit was on July two thousand and seven. What was the reason for that visit?
Patient: My asthma was acting up, and it felt like I couldn't breathe.
Doctor: Do you have a history of asthma?
Patient: Not that I know of, but I know I always get this really bad cough where I cough up some nasty phlegm.
Doctor: I see. I'm looking at your report and it says you have a history of pneumonia.

assistant: Asthma with his last admission in 07/2007. Also inclusive of frequent pneumonia by report.
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: OTHER_HISTORY

Dialogue:
Doctor: Do you know about any medical traits in your family?
Patient: No, everyone in my family is quite healthy. I'm not aware of any medical problems.
Doctor: Are you sexually active?
Patient: Yes, I am with my boyfriend.
Doctor: Do you take any drugs or alcohol or smoke?
Patient: No, none of them.

assistant: completely unremarkable FHx. Has boyfriend and is sexually active. Denied drug/ETOH/Tobacco 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: PASTMEDICALHX

Dialogue:
Doctor: Any past medical history?
Patient: Um there were a couple times where I noticed my blood pressure was high but that's improved as of late.
Doctor: When did these episodes occur?
Patient: About a year ago.
Doctor: Did you follow up with your previous doctor?
Patient: Yeah, my old doctor knows.
Doctor: Okay then. Let's see. Have you been checking your own blood pressure as a result?
Patient: No not really.
Doctor: It looks like your blood pressure was normal today, which is a good sign.
Patient: Great.
Doctor: Hm any allergies to medications?
Patient: None that I know of.
Doctor: And it looks like you have gained about fourteen pounds since last year. Any new diet changes or stressors?
Patient: I lost my job last January and it took a pretty big toll on me.
Doctor: I'm sorry to hear that. How have you been coping?
Patient: I'm doing better now but I need to watch what I eat. I tend to eat a lot more when I'm stressed. It's something I'm working on.

assistant: Unremarkable. There is no history of allergies. He does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ALLERGY

Dialogue:
Doctor: Are you allergic to anything?
Patient: Yes, I am allergic to Penicillin.
Doctor: Any other drugs that you could be allergic to?
Patient: Nope that is all.
Doctor: Okay.

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

user: Section: ASSESSMENT

Dialogue:
Guest_clinician: What brought them in today?
Doctor: Poor renal sufficiency, possibly due to dehydration or diabetic nephropathy. She also has high blood pressure and low blood sugar as a result of missing meals regularly.

assistant: 1. Hypoglycemia due to not eating her meals on a regular basis. 2. Hypertension. 3. Renal insufficiency, may be dehydration, or diabetic nephropathy.
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:
Patient: Doc what are you going to diagnose me as?
Doctor: We are looking at blood born pathogen exposure secondary to needlestick.
Patient: Yes, I was also thinking around contamination.

assistant: Blood-borne pathogen exposure secondary to contaminated needlestick.
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. Let me first start by asking your age. How old are you?
Patient: I'm twenty four.
Doctor: So, what brought you here? How can I help you?
Patient: I was out for fishing this weekend, I think I got into some poison ivy and I have these rashes all over my chest, legs, arms and also some are on my back.
Doctor: You seem so confident of it being poison ivy has it happened before?
Patient: Oh yes, it has happened several times before. It usually takes some time to get over. Last time I was here Doctor Blackman gave me a steroid injection.
Doctor: Okay, let me check my records. It looks like he gave you eighty milligrams of depomedrol. How was it last time after the injection?
Patient: It worked fine. It did take us some time to get rid of it.
Doctor: Did you take any medicine or anything else this time?
Patient: I took over the counter Benadryl. Also, I'm applying cortisone cream on the rashes.
Doctor: Did they help you?
Patient: I saw a little bit of improvement. But this weekend it seemed to have been worst.
Doctor: No worries, let's set you up for another injection.

assistant: He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing. He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by Dr. Blackman; it looked like it was Depo-Medrol 80 mg. He said that it worked fairly well, although it seemed to still take awhile to get rid of it. He has been using over-the-counter Benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement, but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest, legs, arms and back.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: You had mentioned that cancer runs in your family. What type of cancer?
Patient: Skin cancer.
Doctor: Any other health problems in the family?
Patient: High blood pressure.

assistant: Cancer, 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: CC

Dialogue:
Doctor: Hi, what brings you here today?
Patient: I feel this lump on the upper side of my breast.
Doctor: Both sides?
Patient: No, only on the left side.
Doctor: Do you feel it deep inside or on the outer side?
Patient: Only on the outer side.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: I understand that you are new to the clinic. Welcome.
Patient: Yes, I am new here. I have lived in Arizona for the last four years. I am from Maine. That is where I grow up and most of my family still lives there.
Doctor: What line of work are you in?
Patient: I am a homemaker. I used to clean house, a while back.
Doctor: Do you have children?
Patient: I have two children but only one of them is still with us. My oldest son passed away from ulcerative colitis complications three years ago.
Doctor: I am so sorry to hear that!

assistant: The patient is originally from Maine. She has lived in Arizona for 4 years. She has had 2 children; however, only one is living. She had one child died from complications of ulcerative colitis. She has been predominantly a homemaker during her life, but has done some domestic cleaning work in the past.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: CC

Dialogue:
Doctor: You okay there?
Patient: Uh yeah, sorry. I'm just trying to adjust the stretcher.
Doctor: Want some help?
Patient: No, thank you. I think I got it.
Doctor: So how're you doing?
Patient: Fine, but I have this weird lump in my chest.
Doctor: When did you first notice it?
Patient: It's been there for a while. I'd say almost half a year.
Doctor: Have you seen anyone for it?
Patient: No, not until now.
Doctor: Is it causing you pain? And has it changed in size at all?
Patient: Not really. It's just noticeable when I run my fingers over it.
Doctor: Have you spotted any swelling or redness to the area? Any drainage?
Patient: No.
Doctor: I see. Okay. Let me take a look and then I'll have you walk down the hall to get an Xray so we can see what's going on.

assistant: Lump in the chest wall.
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, so you are here for follow up today.
Patient: Yes, very much.
Doctor: I will ask you some regular questions, okay?
Patient: Sure.
Doctor: Any pain in urination?
Patient: Nope.
Doctor: Any fever or chills?
Patient: Neither of them.
Doctor: Have you noticed any blood while urinating? Any blood in your urine?
Patient: Nope. I do leak, especially when I'm changing my positions like from sitting to standing so I do feel there is some involuntary urination. It's more like a urge. I'm loading data in like every one hour in the morning, especially when I take that Lasix.
Doctor: Does it taper off in the afternoon or night?
Patient: It tapers off in the afternoon. And by the night I don't do not feel anything.
Doctor: Any leakage in the night?
Patient: Nope.
Doctor: Do you apply a lot of force to urinate?
Patient: Nope.
Doctor: How about this stream? Is it good or less? Are you emptying well? And what about the bowel movement?
Patient: The stream is good. It does feel like all is out in one go. I do not have any kind of bowel issues. I'm using my vaginal cream. Sometimes I feel difficulty in doing so because I feel that there is still something coming out from the vagina and I'm afraid that there might be a prolapse.
Doctor: Don't worry, I will look into it.

assistant: The patient presents today for followup. No dysuria, gross hematuria, fever, chills. She continues to have urinary incontinence, especially while changing from sitting to standing position, as well as urge incontinence. She is voiding daytime every 1 hour in the morning especially after taking Lasix, which tapers off in the afternoon, nocturia time 0. No incontinence. No straining to urinate. Good stream, emptying well. No bowel issues, however, she also indicates that while using her vaginal cream, she has difficulty doing this as she feels protrusion in the vagina, and very concerned if she has a prolapse.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ROS

Dialogue:
Doctor: Have you lost weight?
Patient: No, I haven't, you can ask my daughter.
Doctor: How about anything like fever, nausea, vomiting, pain?
Patient: No.
Doctor: And as we discussed you have problem talking and comprehending.
Patient: Yes.
Doctor: And you get urine infections too?
Patient: Yes.
Doctor: And as discussed, your drainage is similar to past episodes when you had such infection?
Patient: Yes.

assistant: As in HPI. Patient and daughter also deny weight loss, fevers, chills, sweats, nausea, vomiting, abdominal pain. She has had some difficulty expressing herself, but seems to comprehend speech as above. The patient has had a history of chronic urinary tract infections and her drainage is similar to past episodes when she has had such 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: FAM/SOCHX

Dialogue:
Doctor: Do you use tobacco products? Cigarettes, chewing tobacco or vaping?
Patient: I used to smoke a pack a day. I quit that awful habit in nineteen eighty five.
Doctor: Do you work?
Patient: I am retired.
Doctor: Wonderful. Is your husband retired with you?
Patient: Yes. We both are. I cannot imagine working a full time job at seventy six years old.

assistant: She is married. A 76-year-old who used to smoke a pack a day and quit in 1985. She is retired.
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 okay.
Doctor: So, I see you turned eighty-eight yesterday, happy birthday!
Patient: Thank you!
Doctor: And you are referred by Doctor X, he is your primary physician, right?
Patient: Correct! I am also seeing Doctor Y for my leukemia.
Doctor: Hm he mentioned that it's chronic lymphocytic leukemia.
Patient: Yes.
Doctor: Okay.
Doctor: And you are also seeing Doctor Z for your heart related problems.
Patient: That is correct.
Doctor: So, tell me what is happening with you?
Patient: For the past one week I am having this increased shortness of breath and having difficulty breathing from past few nights while sleeping.
Doctor: Okay.
Patient: And this morning I was having difficulty catching my breath. I am also having wheezing since morning.
Doctor: Let me examine you, can you come forward and sit-up here? Any chest discomfort or acute chest pain or anything of that sort? Any pain of the left arm?
Patient: No.
Doctor: Any dizziness, feeling like fainting or light headedness or losing control?
Patient: No.
Doctor: Well, I don't think there is any sign of cardiovascular accident or heart attack, so that's that. You do have mild peripheral edema. We need to treat that.
Patient: Okay.

assistant: The patient is an 88-year-old gentleman followed by Dr. X, his primary care physician, Dr. Y for the indication of CLL and Dr. Z for his cardiovascular issues. He presents to the Care Center earlier today with approximately a one-week history of increased progressive shortness of breath, orthopnea over the course of the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea presenting this morning. He reports no clear-cut chest discomfort or difficulty with angina. He has had no dizziness, lightheadedness, no near or true syncope, nothing supportive of CVA, TIA, nor peripheral vascular claudication.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: DISPOSITION

Dialogue:
Doctor: Ready to go home?
Patient: I just can't wait.
Doctor: Sure. I can understand.
Patient: Bye Doctor.
Doctor: Yes. See you soon.

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

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Have you had any illnesses in the past?
Patient: Nope.
Doctor: Anything that is worth mentioning?
Patient: Nope.
Doctor: Sure?
Patient: Yes.

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: GENHX

Dialogue:
Doctor: Good afternoon, sir. My nurse tells me you're twenty eight years old, is that correct?
Patient: Good morning, doctor. Yes, that's correct.
Doctor: So, what happened?
Patient: Well, I punched a wall about three days ago.
Doctor: Which hand is it?
Patient: It's my right hand.
Doctor: Is this your dominant hand?
Patient: Unfortunately, yes, it is.
Doctor: Where does it hurt?
Patient: Um, it's right here on the outside of my hand.
Doctor: What kind of treatments have you had?
Patient: I went to the E D, and they pushed some of the joints in my hand back, and they put me in a splint, so I've been wearing that ever since.
Doctor: How is your pain today?
Patient: Compared to when it started, it's much better today.
Doctor: How would you describe your pain today?
Patient: Today, I'd say it's minimal pain.
Doctor: Good, do you have any numbness or tingling today?
Patient: No, thankfully not.

assistant: The patient is a 28-year-old right-hand dominant gentleman, who punched the wall 3 days prior to presentation. He complained of ulnar-sided right hand pain and was seen in the emergency room. Reportedly, he had some joints in his hand pushed back and placed by somebody in emergency room. Today, he admits that his pain is much better. Currently, since that time he has been in the splint with minimal pain. He has had no numbness, tingling or other concerning symptoms.
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 there, how are you?
Patient: I am good, thank you.
Doctor: He is my colleague Doctor Mason, and he will be assisting me today and taking down notes.
Guest_clinician: Hi there.
Patient: Hello.
Doctor: Is it okay with you if he can join us?
Patient: Sure, no problem.
Doctor: Great, thank you
Doctor: Doctor Mason can you take down the notes.
Guest_clinician: Sure.
Doctor: Patient looks well developed and well nourished. He is alert with not acute distress.
Guest_clinician: Got it.
Doctor: Patient had a head injury, but he is fully conscious. G C S is fifty and nontoxic.
Guest_clinician: Okay.

assistant: GENERAL: Well developed, well nourished, alert, in no acute distress. GCS 50, nontoxic.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Anyone sick in your family?
Patient: No.
Doctor: How about anyone with the same disorders?
Patient: No, I don't know.
Doctor: Okay don't you worry.

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: PLAN

Dialogue:
Doctor: How did the patient do on the activity test?
Guest_clinician: Patient was good. I have advised him to continue with his normal activities as long as he is feeling fine.

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

user: Section: GENHX

Dialogue:
Doctor: How old was he when he were first evaluated in the other hospital?
Guest_family: He was seven.
Doctor: Which hospital was that again?
Guest_family: It was at U I H C.
Doctor: So what exactly happened?
Guest_family: He was doing all good like seven months before his evaluation, then he started having some dizzy spells, which like stayed for several seconds to a minute. They were not regular, but he was able to continue his activity immediately after these dizzy spells.
Doctor: Did the intensity change?
Guest_family: Oh yes. This, these spells, they became more frequent, and they were now for longer periods. By the time we came for the first evaluation, they were like two to three times per day.
Doctor: How long were they in the duration?
Guest_family: They lasted for like two to three minutes.
Doctor: Was there any other associated disorder or anything?
Guest_family: Yeah, around three months before his evaluation his hands, they started becoming stressed, like stiffer and felt tighter during these spells. He also felt very weak and tired after these episodes.

assistant: The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as "dizzy spells" lasting from several seconds to one minute in duration. They occurred quite infrequently and he was able to resume activity immediately following the episodes. The spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration. In addition, in the 3 months prior to evaluation, the right upper extremity would become tonic and flexed during the episodes, and he began to experience post ictal fatigue.
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 major illnesses in the family like diabetes or high B P?
Patient: No nothing. No major illnesses.
Doctor: Okay.
Patient: Yes.

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: PASTSURGICAL

Dialogue:
Doctor: Good morning, sir.
Patient: Good morning, doctor.
Doctor: I just need some background information before we begin today.
Patient: Sure.
Doctor: Good, have you ever had surgery, sir?
Patient: Yeah, actually I've had it on my knee, a nose job, and, um, carotid sinus surgery.

assistant: Right knee surgery, cosmetic surgery, and carotid sinus surgery.
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 still working?
Patient: No, I am retired now. I used to work for the U S postal service as an electronic technician but took retirement one year earlier due to my disability.
Doctor: Ah okay. And who is in your family?
Patient: Well, I stay with my wife and daughter in our apartment.
Doctor: Okay. Do you smoke?
Patient: No.
Doctor: How about alcohol?
Patient: I use to drink occasionally, that too very rare, but after my symptoms stated I stopped completely.
Doctor: Any use of recreational or illegal drugs?
Patient: Nope.
Doctor: Did you travel anywhere recently?
Patient: No, it's been really long since I traveled anywhere.

assistant: The patient retired one year PTA due to his disability. He was formerly employed as an electronic technician for the US postal service. The patient lives with his wife and daughter in an apartment. He denied any smoking history. He used to drink alcohol rarely but stopped entirely with the onset of his symptoms. He denied any h/o drug abuse. He denied any recent travel history.
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: Good afternoon, how are you today?
Patient: I am good Doctor, thanks for asking.
Doctor: This is my colleague Doctor White, and she will be taking the notes. Is it okay if she joins us?
Patient: Oh sure, no problem.
Doctor: Thank you.
Guest_clinician: Hello, I am Doctor White, nice to meet you.
Patient: Nice to meet you too.
Doctor: Okay, can you breathe in and out for me? Deep breaths please.
Patient: Okay.
Doctor: Okay breath sounds are clear. Lung function looks good. Symmetrical rise and fall in chest as patient breathes. I am going to palpate your chest, it's just a routine exam.
Patient: Sure.
Doctor: Doctor White can you make a note, no egophony or tactile fremitus.
Guest_clinician: Sure.

assistant: RESPIRATORY: Good respiratory effort. Clear to auscultation. Clear to percussion. Chest: Symmetrical rise and fall. Symmetrical expansion. No egophony or tactile fremitus.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Where do you live?
Patient: I live in a board and care. It is a nice small care home with some very nice and supportive people. It is just next to the Safeway on Village Drive.
Doctor: Nice. It looks like you love living there.
Patient: Oh yes. I feel very relaxed there.
Doctor: Did you consume alcohol in any way?
Patient: No Sir.
Doctor: Any tobacco consumption?
Patient: Never in my life.
Doctor: Did you ever try any kind of illicit drugs? Any I V drugs?
Patient: No. I have always kept myself away from all those things.

assistant: The patient lives in a board and care. No tobacco, alcohol or IV drug use.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTSURGICAL

Dialogue:
Doctor: Have you had any surgeries in the past?
Patient: Actually, yes, I had my gallbladder removed in nineteen ninety two.
Doctor: Great, any other surgeries? Think back a little further?
Patient: Oh yeah, I had my appendix out in nineteen eighty eight.

assistant: Appendectomy 1988. Cholecystectomy. 1992