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: Now, let's talk about your family history. Have any of them had cancer?
Patient: Actually, yes, I know a few family members have, but I can't remember who had what kind.
Doctor: That's okay. What about heart disease? Can you remember anyone having that?
Patient: Yes, that rings some bells.
Doctor: Thank you, has anyone in your family had a joint replacement?
Patient: I know that a lot of my family has had arthritis in the past, but I can't remember whether or not they had joint replacements, honestly.

assistant: Family history is remarkable for a remote history of cancer. Family history of heart disease and osteoarthritis.
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 am good, how about you?
Doctor: Well, I am good too, thank you for asking. So, what brings you here?
Patient: Um, I have developed this painful ulcer on my hip.
Doctor: Oh, let me take a look. Which side?
Patient: On my right hip.
Doctor: Okay, I see it. Looks like you have developed pressure ulcer.

assistant: Pressure decubitus, right 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: GENHX

Dialogue:
Doctor: Okay, tell me what's going on and what's brought you here.
Guest_family: I am her mother. She has this blister on the side of her head right above her ear, here. I was just worried and concerned about my baby.
Doctor: How old is the baby? When did you first notice it?
Guest_family: She is just fourteen days old. Let me tell you from the beginning. On Friday, when I was taking her for a bath, I noticed a blister near her umbilicus area. We went to our doctor on Saturday, and they did a test.
Doctor: Did you get the test result?
Guest_family: I got it today. Here is the report.
Doctor: Okay, let me have a look. It says she is having a growing M R S A.
Guest_family: Yeah, I've been diagnosed with that too. And I am on medications. I had it on my buttock area.
Doctor: Okay, so you know about it, and I don't have to explain it more.
Guest_family: Yeah.
Doctor: So how is the blister on the umbilicus now?
Guest_family: She has been doing good. We put on some bacitracin ointment, and it almost healed up. But today I noticed that another small blister on her head. It really scared me, and I did not want to take any chance. That's why I reached out to the Infectious Disease center. I know it is private. But still, I don't want to take any chance with my baby's health. I called the center directly and they asked me to come to the hospital.
Doctor: You did good. I will start the treatment. How are her eating and sleeping habits?
Guest_family: She hasn't missed any of her meals. She is taking around two ounces of milk in every feed. I don't think I have any issues with her eating or sleeping.
Doctor: Did she have any fever?
Guest_family: Not that I noticed.
Doctor: Has she been lethargic or crying more than normal?
Guest_family: No.
Doctor: Any other changes in her daily routine that you might have noticed?
Guest_family: No, I didn't notice any changes.

assistant: A 14-day-old was seen by private doctor because of blister. On Friday, she was noted to have a small blister near her umbilicus. They went to their doctor on Saturday, culture was drawn. It came back today, growing MRSA. She has been doing well. They put her on bacitracin ointment near the umbilicus. That has about healed up. However today, they noticed a small blister on her left temporal area. They called the private doctor. They direct called the Infectious Disease doctor here and was asked that they come into the hospital. Mom states she has been diagnosed with MRSA on her buttocks as well and is on some medications. The child has not had any fever. She has not been lethargic or irritable. She has been eating well up to 2 ounces every feed. Eating well and sleeping well. No other changes have been noted.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: DIAGNOSIS

Dialogue:
Patient: I am in pain. I get these frequent episodes of pain and discomfort in my head.
Doctor: Is it in any side of head or is it overall?
Patient: Sometimes it is overall and other times just on any one side. Doctor: This sounds like it is a migraine headache.

assistant: Migraine headache.
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, young man. Is this your mother?
Patient: Hi, doctor. Yes, this is my mom.
Doctor: Good, can you tell me more about your son, ma'am?
Guest_family: Sure, well, he's six years old now, and we're here to follow up his A D H D medicines.
Doctor: He's been taking Adderall, correct? How long has he been taking this?
Guest_family: It's been about a month now.
Doctor: How has he responded to the Adderall?
Guest_family: The first day he took it, truthfully, he was wonderful. There's been a lot of improvement in his behavior, and he's really been doing well, so far.
Doctor: That's great!
Guest_family: Yes, but I have two concerns. When he takes the medicine first thing in the morning it seems to take a while to kick in, and then it wears off at about two P M and he has problems in the evening.
Doctor: Has he had problems with his appetite?
Guest_family: Um, he did at first, but it's been coming back. It's more of a problem in the morning when he first takes the medicine in the morning, not so much in the afternoon after it wears off.
Doctor: Have you gotten any reports from his teachers?
Guest_family: They have seen a dramatic improvement with it.
Doctor: Has he taken every dose?
Guest_family: Well, I missed one last weekend, and he was just horrible.
Patient: Yeah, mommy, I thought I needed it, but you didn't give it to me.

assistant: This is a 6-year-old male who comes in rechecking his ADHD medicines. We placed him on Adderall, first time he has been on a stimulant medication last month. Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine. She has two concerns. It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in. It wears off about 2 and they have problems in the evening with him. He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off. His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible. The patient even commented that he thought he needed his medication.
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 family medical history?
Patient: I have a whole list. See, my grand aunt had a stroke. My M G had heart issues same as my mom, who died of a heart attack at sixty three. My father had some sort of cancer. I don't know what exactly. And my sisters have blood pressure issues.
Doctor: Wow, that sure is a list. Anyone with diabetes?
Patient: No. Well, that is one thing that skipped my family.

assistant: Grand Aunt (stroke), MG (CAD), Mother (CAD, died MI age 63), Father (with unknown CA), Sisters (HTN), No DM in relatives.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Good morning, can you tell me more about your son, ma'am.
Guest_family: Sure, he's forty six, White, and he has Down syndrome.
Doctor: Great, thank you. Is he still having problems with his hypothyroidism and onychomycosis?
Guest_family: Yes, that's correct doctor.
Doctor: Has he remained complaint with his Lamisil?
Guest_family: Yes, he's taken six weeks of it with no problems.
Doctor: Good, so we'll do an A L T blood test today.
Guest_family: Why is that doctor?
Doctor: Well, at his last appointment in April, he had an elevated T S H level. So, we should recheck that today.
Guest_family: Yes, I remember that.
Doctor: Has he been taking his Levothroid daily as well?
Guest_family: Yes, he has, he doesn't like it, but I help him with it, and he eventually takes it.
Doctor: Good, thanks for taking care of him, Mom.
Guest_family: Oh, it's my job.
Doctor: Does he take any other medications?
Guest_family: He has some medicated eye drops for his cornea.

assistant: This 46-year-old white male with Down's syndrome presents with his mother for followup of hypothyroidism, as well as onychomycosis. He has finished six weeks of Lamisil without any problems. He is due to have an ALT check today. At his appointment in April, I also found that he was hypothyroid with elevated TSH. He was started on Levothroid 0.1 mg and has been taking that daily. We will recheck a TSH today as well. His mother notes that although he does not like to take the medications, he is taking it with encouragement. His only other medications are some eyedrops for his cornea.
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: Hey, how are you?
Patient: I think I am better.
Doctor: So you do not have any more nausea or vomiting?
Patient: No I don't.
Doctor: How about any acidity?
Patient: I think it's all better.
Doctor: Great.

assistant: Severe nausea and vomiting likely secondary gastroenteritis, resolved.
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: How are you?
Patient: I am good.
Doctor: That's great. You are stable.
Patient: Can I go home now?
Doctor: Yes, you can.
Patient: Thank you!

assistant: Stable.
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, young man, are these your parents?
Patient: Yes, doctor.
Doctor: Can you tell me more about your son, please?
Guest_family: Well, he is seven years old, and he has had diarrhea for four days, and he's been throwing up for three days.
Patient: Yeah, my brother has been doing this too.
Guest_family: We had some chicken one day, and then we had more of it the next day. After they ate it they started to feel bad and still feel bad.
Doctor: How many times has he had diarrhea per day since this began?
Guest_family: Well, it's been about five or six times a day for the last four days.
Doctor: How many times has he thrown up per day?
Guest_family: Um, it has been frequent.
Doctor: Has he been throwing up today?
Patient: No, I haven't today.
Doctor: Has he gone to the bathroom today?
Patient: Yes, I peed this morning.
Doctor: Has he had any fever symptoms?
Guest_family: Yes, he had a fever of one hundred three last night.
Doctor: Has he eaten any solid food?
Patient: Yeah, I had half a hamburger and some milk last night.
Doctor: Was he able to keep the food down?
Guest_family: No, he threw it up.
Doctor: What has he drank?
Guest_family: Um, Pedialyte, Gatorade, white grape juice, and seven up, the soda.

assistant: The patient is a 7-year-old male who comes in today with a three-day history of emesis and a four-day history of diarrhea. Apparently, his brother had similar symptoms. They had eaten some chicken and then ate some more of it the next day, and I could not quite understand what the problem was because there is a little bit of language barrier, although dad was trying very hard to explain to me what had happened. But any way, after he and his brother got done eating with chicken, they both felt bad and have continued to feel bad. The patient has had diarrhea five to six times a day for the last four days and then he had emesis pretty frequently three days ago and then has just had a couple of it each day in the last two days. He has not had any emesis today. He has urinated this morning. His parents are both concerned because he had a fever of 103 last night. Also, he ate half of a hamburger yesterday and he tried drinking some milk and that is when he had an emesis. He has been drinking Pedialyte, Gatorade, white grape juice, and 7Up, otherwise he has not been eating anything.
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 into the clinic! I would like to start with your past medical history.
Patient: I have high blood pressure and macular deterioration. Last year I caught pneumonia but that has cleared up.
Doctor: Okay. What brings you in today?
Patient: I have had this cough and pain on the right side of my abdomen.
Doctor: How long has this been going on?
Patient: Two days. I have had body aches and have been feeling nauseous too.
Doctor: Have you had a fever?
Patient: I think so. I was chilled and my forehead was warm. The cough is a dry sounding cough.
Doctor: Does the abdominal pain come during one of these coughing episodes?
Patient: Yes.

assistant: This is a 76-year-old female who has a history of previous pneumonia, also hypertension and macular degeneration, who presents with generalized body aches, cough, nausea, and right-sided abdominal pain for two days. The patient stated that the abdominal pain was only associated with coughing. The patient reported that the cough is dry in nature and the patient had subjective fevers and chills at 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: CC

Dialogue:
Doctor: What brings you here today?
Patient: I have pain in my tummy.
Doctor: When did you first notice it?
Patient: It started suddenly around noon.

assistant: Abdominal 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: GENHX

Dialogue:
Doctor: Welcome to the clinic., ma'am
Patient: Thank you.
Doctor: What brings you into see me?
Patient: I have been struggling with pain and stiffness in my right neck and shoulder.
Doctor: How long has this been going on for?
Patient: Maybe for about four months.
Doctor: In these past four months have your symptoms becomes worse or has it improved at all?
Patient: It has been getting worse. The pain is worse at night. It wakes me up at night. I haven't had a good night sleep in four months.
Doctor: Have you experienced any pain or numbness in your arm, wrist, or hand?
Patient: Yes! About two weeks after the pain started, I was having some numbness and painful cramping in these two fingers here.
Doctor: The right hand and the first and second finger?
Patient: Yes.
Doctor: How old are you?
Patient: I am forty six.
Doctor: Are you left or right handed?
Patient: Right. It was a throbbing pain in my hand.
Doctor: Have you had any other pain anywhere else in your body?
Patient: I few times I had some numbness in both of my legs. It started with a pinching from my tailbone area.
Doctor: Did you experience any trauma neck, head or back?
Patient: No. I don't know where this pain came from. Oh, every once and a while I have this electric shock like sensation shooting down my spine when move my neck certain way.
Doctor: Any pain or symptoms in your left arm or shoulder?
Patient: No.
Doctor: Have you had any visual changes or disturbances?
Patient: No.
Doctor: Any difficulties with your bowels or your bladder?
Patient: No.
Doctor: Have you been taking any thing for the pain?
Patient: I have been taking Naprosyn.
Doctor: Has the Naprosyn help relieve your pain?
Patient: Only a little bit.
Doctor: Okay.

assistant: This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck (Lhermitte's phenomena). She denied any history of neck/back/head trauma. She had been taking Naprosyn with little relief.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GYNHX

Dialogue:
Doctor: Is this baby number two?
Patient: Yes, this is baby number two.
Doctor: How many times have you been pregnant, including miscarriages or abortions if any?
Patient: I've been pregnant two times in total. No miscarriages or abortions.
Doctor: When was your last period?
Patient: About a month ago.
Doctor: And how would you describe your periods? Light, normal, heavy?
Patient: Pretty normal.
Doctor: Any abnormal pap smears?
Patient: No, fortunately they've all been normal.
Doctor: That's wonderful to hear. And my last question for you is if you've ever gotten a mammogram?
Patient: I haven't gotten one before. Do I need to get one? I just turned thirty nine. What's the recommended age again?
Doctor: It depends. For example, the recommended age would be younger for someone who has a family history of breast cancer. Given that you don't have a positive family history of breast cancer, I'd advise getting one in a few years at the age of forty five.

assistant: Gravida 2, Para 2, Ab 0. Menstrual periods have been regular, last menstrual period almost 1 month ago. No menorrhagia. Never had a mammogram. Has yearly Pap smears which have all been normal.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: DISPOSITION

Dialogue:
Doctor: Okay, I want you to follow up with our hand therapist Doctor X at her A B C D office in one to two weeks.
Patient: Okay, I will make an appointment today.

assistant: Follow up with Dr. X in ABC Office in 1 to 2 weeks.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: CC

Dialogue:
Doctor: So we're here to follow up on a few things. I'd like to know how you're keeping up with your blood sugar checks.
Patient: I've been checking my blood sugar one to two times a day.
Doctor: Have you been keeping a log?
Patient: Uh yeah, but I need to be better at it.
Doctor: Do you have the log with you today?
Patient: Yep, in fact it's right here. Let me grab it for you.
Doctor: Great.
Patient: Here ya go.
Doctor: Thank you. And have you been watching your cholesterol intake since getting blood work done? Your labs show your cholesterol levels are a bit elevated. I'd like for you to monitor your cholesterol and go in for another set of labs before our next visit.
Patient: Do I need to fast for it again?
Doctor: Yes, you'll need to fast. I'd recommend going in early in the morning before eating any breakfast.
Patient: That sounds like a good plan.
Doctor: And as for your sinusitis, how have you been feeling since finishing your course of antibiotics?
Patient: Much better. No more headaches and a stuffy nose.

assistant: Followup on diabetes mellitus, hypercholesterolemia, and sinusitis.
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 in today?
Patient: My back started hurting last night. I have a stomachache. I have had pain with urination for the last two days.
Doctor: Do you have any other symptoms?
Patient: I just started coughing and now I have a fever.
Doctor: Do you have any history of kidney stones?
Patient: Yes. I had kidney stones less than a year ago. I had a urinary tract infection at the same time. It was awful.

assistant: The patient complains of backache, stomachache, and dysuria for the last two days. Fever just started today and cough. She has history of kidney stones less than a year ago and had a urinary tract infection at that time. Her back started hurting last night.
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:
Guest_clinician: When did she have lumbar discitis?
Doctor: A little over a year ago. She received antibiotic therapy and ended up having debridement and instrumentation with Doctor XYZ.
Guest_clinician: How's she doing today?
Doctor: Really quite well.
Guest_clinician: She also had a P E with that prior hospitalization, correct?
Doctor: Yes.

assistant: Little over a year ago, the patient was found to have lumbar discitis and was treated with antibiotics and ended up having debridement and instrumentation with Dr. XYZ and is doing really quite well. She had a pulmonary embolus with that hospitalization.
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 sugar or blood pressure problems?
Patient: Oh, I have high blood pressure but it's well under control. I make sure to keep it under normal range.
Doctor: Good. Any other health issues?
Patient: Yeah, I have history of high triglycerides. But otherwise, I am pretty healthy.
Doctor: Okay. Do you smoke?
Patient: No.

assistant: She has had hypertension very well controlled and history of elevated triglycerides. She has otherwise been generally healthy. Nonsmoker.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Hello, miss. The nurse who seated you tells me you are here for a second opinion on surgery.
Patient: Hello, doctor. Yes, I have been told that both eyes need cataract extraction. I came for a second opinion because I will only have surgery if necessary. I am nervous.
Doctor: What is the reason for the extraction?
Patient: I am not exactly sure because the other doctors said a bunch of medical terms. I have had laser in my eyes though. That was for macular degeneration. Doctor X said I had neurovascular age-related macular degeneration.
Doctor: Do you know what laser you had on your eyes?
Patient: No. I just know laser was done by Doctor X four times to the macula on the right and two times on the left.

assistant: The patient seeks evaluation for a second opinion concerning cataract extraction. She tells me cataract extraction has been recommended in each eye; however, she is nervous to have surgery. Past ocular surgery history is significant for neurovascular age-related macular degeneration. She states she has had laser four times to the macula on the right and two times to the left, she sees Dr. X for this.
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: Any allergies?
Patient: Um yeah. I'm trying to remember the name. It's a pain killer that starts with an L. Oh Lortab.
Doctor: What happens when you take Lortab?
Patient: Really bad hives. I've only ever taken it once.
Doctor: I'll make note of that in your chart so we have it in your records.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Welcome in.
Patient: Thank you.
Doctor: What do you do for work?
Patient: I work in Human Resources for the State of Maryland.
Doctor: Do you live alone or with others?
Patient: I live alone.
Doctor: Do you smoke cigarettes?
Patient: I used to smoke like a chimney. I quit smoking a while back. I had been smoking for about sixteen years.
Doctor: That's great! When did you quit?
Patient: I quit in nineteen eighty four. That is also the year I quit drinking.
Doctor: What was the reason behind quitting drinking?
Patient: I had a drinking problem. I am in A A. I have been in A A since I quit.
Doctor: That's great. Keep up the hard work.
Patient: Thank you.
Doctor: Do you have any history of recreational or I V drug use?
Patient: Yes. I used to take pills, but I never got into needle drugs. Thank God. I went through treatment, all those years back. I started going to A A and got my life together.
Doctor: Do you have any other risk factors for H I V? Like multiple sex partners?
Patient: No. I had my last H I V test over two years ago. I have been with the same guy for over two years.
Doctor: Okay.

assistant: He lives alone. He works full time in Human Resources for the State of Maryland. He previously was an alcoholic, but quit in 1984. He also quit smoking cigarettes in 1984, after 16 years of smoking. He has a history of illicit drug use, but denies IV drug use. He denies any HIV risk factors and states that his last HIV test was over two years ago.
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, tell me about your family? Did anyone have any medical diseases?
Patient: Both of my parents were healthy, but my maternal grandfather had a stroke.
Doctor: Did anyone in your family ever have migraines?
Patient: No, not that I know.

assistant: MGF with h/o stroke. Mother and Father were healthy. No h/o of migraine in family.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Do you have any chronic medical conditions that I should know about?
Patient: What do you mean by that, doctor?
Doctor: Well, it could be anything from high blood pressure, to depression, to cancer. Do any of those sound familiar?
Patient: Oh, yeah, I have a few things like that. I have anemia, high cholesterol, and, um, hypothyroidism.

assistant: Anemia, high cholesterol, and hypothyroidism. 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: GENHX

Dialogue:
Doctor: How old are you?
Patient: Oh, I am fifty eight now.
Doctor: So, you are here today because you are having some vision difficulties? Tell me about what has been going on, ma'am.
Patient: Yeah. Okay. It all started a year ago. It started with losing the color in my vision.
Doctor: Was the loss sudden or gradual?
Patient: Gradual. And now I am starting to have blurry vision.
Doctor: When did that start happening?
Patient: I noticed it two months ago.
Doctor: Is the blurred vision an all blur or is there a blind spot of blurred vision.
Patient: It is an all over vision blur and then I have on blind spot in my right eye.
Doctor: Have you had any fluctuations in your symptoms in the last year? Have you gained any vision back?
Patient: Some days I feel like things are a little better but not much. I have basically been the same.
Doctor: Have you experienced any weakness, dizziness, vertigo, nausea or vomiting?
Patient: No.
Doctor: Any double vision or headaches?
Patient: No.
Doctor: Any pain in or behind the eye at all?
Patient: No.
Doctor: Any other health concerns or complains?
Patient: No. Just the vision problems.
Doctor: Alright! Let me take a look here.

assistant: 58 y/o female presents with a one year history of progressive loss of color vision. In the past two months she has developed blurred vision and a central scotoma OD. There are no symptoms of photopsias, diplopia, headache, or eye pain. There are no other complaints. There have been mild fluctuations of her symptoms, but her vision has never returned to its baseline prior to symptom onset one year ago.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: CC

Dialogue:
Doctor: How are you feeling today?
Patient: I have been having some trouble breathing. I had tightness in my chest after walking up stairs.
Doctor: Let me listen to your lungs.

assistant: "Trouble breathing."
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: Do you remember the name of the medication you are taking?
Patient: I have two, but I do not remember their name or why I am taking it.
Doctor: That is fine, we will figure it out.

assistant: She is on two different medications, neither of which she can remember the name and why she is taking it.
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 wanted to talk to you about your family medical history.
Patient: Okay, how this will be helpful?
Doctor: Family history plays an invaluable role in your health. It provides us with important clues and insight to predict and detect diseases before obvious symptoms appear.
Patient: My mom dealt a long time with anxiety and stress disorder.

assistant: Patient admits a family history of anxiety, stress disorder associated with mother.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Okay, let's review your family history.
Patient: Ready when you are.
Doctor: Does anyone in your family have high blood pressure or high cholesterol?
Patient: Both my parents have high blood pressure.
Doctor: Are they being treated for it?
Patient: Um yes. Oh they also have E T.
Doctor: Do any of your siblings have it as well?
Patient: No.
Doctor: Does anyone in your family have an autoimmune disorder.
Patient: Hm. Give me a second to think. Does lupus count?
Doctor: Yes. Who do you know that has lupus?
Patient: My cousin.
Doctor: On your mom or dad's side?
Patient: Uh mom.

assistant: Both parents have ET and hypertension. Maternal cousin with lupus.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: MEDICATIONS

Dialogue:
Doctor: What are you taking as a maintenance treatment?
Patient: Oh, I take Flonase.
Doctor: And do you have a lot of issues after taking that?
Patient: No I do not.
Doctor: That is good.

assistant: He is maintained on Flonase and denies much in the way of nasal 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: GENHX

Dialogue:
Doctor: Hello. Looks like we are here for a six months follow up. How are we doing?
Patient: I have stayed relatively the same. My main complaint is that I feel tired throughout the day. The C P A P is doing fine and I wake up refreshed, but I don't like how I crash.
Doctor: Alright. How are the thyroid issues?
Patient: I seem to be fine. My thyroid gland does not seem enlarged and I can breathe like normal. No fever or anything.
Doctor: Have you experienced any of the following: temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, or diarrhea?
Patient: Nothing of the kind.
Doctor: How has you weight been?
Patient: It has been stable.
Doctor: Any muscle weakness closest to the body's center?
Patient: No, nothing like that. Not bad for forty five.

assistant: This is a return visit to the endocrine clinic for the patient with history as noted above. She is 45 years old. Her last visit was about 6 months ago. Since that time, the patient states her health has remained unchanged. Currently, primary complaint is one of fatigue that she feels throughout the day. She states, however, she is doing well with CPAP and wakes up feeling refreshed but tends to tire out later in the day. In terms of her thyroid issues, the patient states that she is not having signs or symptoms of thyroid excess or hypothyroidism. She is not reporting temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, hyperdefecation or diarrhea. Her weight has been stable. She is not reporting proximal muscle weakness.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: CC

Dialogue:
Doctor: So I understand you had a fainting episode yesterday?
Patient: Yes, I did.
Doctor: Has this happened to you before?
Patient: Yes. It happens whenever needles are involved.
Doctor: You had a Vasovagal Syncope. How are you feeling today?
Patient: I feel normal today.

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

user: Section: CC

Dialogue:
Doctor: Hello, how are you?
Patient: I am not so good.
Doctor: Oh, what is going on with you?
Patient: Well, I have lot of swelling in my legs.
Doctor: Hm, okay.

assistant: I have a lot of swelling in my legs.
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, sir! I am Doctor Frankland.
Patient: Hi! It's nice to meet you.
Doctor: What brings you into see me today?
Patient: I have had this pain in my finger and wrist for about a month. I have had some numbness too. The numbness started in the finger and is now in the wrist too.
Doctor: Which wrist and finger is it that is hurting?
Patient: The left one and the middle finger, here.
Doctor: What was to time frame of the procreation of the numbness from the finger to the wrist?
Patient: It started when I woke up and then by the end of the day my wrist was numb too.
Doctor: When did you start experiencing pain in the wrist area?
Patient: A few days after the numbness started.
Doctor: Which hand is your dominate hand?
Patient: I am left handed.
Doctor: What do you do for work?
Patient: I am a cook. I also cut the fish for the whole restaurant. I cut fish for hours in the mornings and it has been a struggle and it is aggravating my finger and wrist.
Doctor: How old are you?
Patient: I am forty four.
Doctor: Do you have any history of injuring a neck injury?
Patient: No.
Doctor: Any neck pain or weakness?
Patient: No.
Doctor: Any difficulties with bowel movements or urination?
Patient: No.

assistant: This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.
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 morning. How are you feeling today?
Patient: I feel good, considering. I slept well last night.
Doctor: Are you expensing any pain or discomfort?
Patient: No. I feel fine.

assistant: GENERAL: The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative. No dysarthria is noted. No discomfort on presentation is noted.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: EXAM

Dialogue:
Doctor: How are you doing with everything?
Patient: I'm good. It's hard when you are in quarantine. I hope things will get back to normal soon.
Doctor: So, you are here for your breast examination.
Patient: Yes, it was due for so long.
Doctor: I'm going to touch both of your breasts one by one to check for any lump or kind of mass. Okay?
Patient: Yeah.
Doctor: Okay, so both looks good. Are you feeling any pain while I'm touching?
Patient: No, I don't feel any pain.
Doctor: That's good, no masses, no pain and I do not feel anything in your armpit area.

assistant: BREASTS: The breasts show no masses or tenderness. No axillary adenopathy.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: How's your wife doing? I think the last time I saw her was two weeks ago. She was telling me about the remodeling you've been doing around the house.
Patient: She's doing well, thanks for asking. Oh yeah, the remodeling has been a lot. I didn't think it'd take as long as it has.
Doctor: Yeah, it can take some time. We remodeled our kitchen three years ago and it turned our lives upside down. So tell me, how's training going for you? I believe you were telling me that you have a five k coming up.
Patient: Yeah, it's two weeks away. I've been jogging and doing cross country track about five times a week. I also lift twice a week on my better days.
Doctor: That's great! And no smoking or drinking, correct?
Patient: Nope.
Doctor: How's work been treating ya?
Patient: Pretty darn well actually. I go into the allergy and immunology clinic four days outta the week. I like that my hours are flexible. My patients also haven't run away from me yet, which is always a good sign.

assistant: The patient is married. Wife is living and well. He jogs or does Cross Country track 5 times a week, and weight training twice weekly. No smoking or significant alcohol intake. He is a physician in allergy/immunology.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: My nurse tells me you're thirty four years old, is that correct?
Patient: Yes, I just had my birthday, doctor.
Doctor: You identify as African American, correct?
Patient: Yes, that's right, sir.
Doctor: You're here for a follow up? What brings you back in today?
Patient: Well, I don't really have a single acute complaint, but I have a muscle sprain in my upper back.
Doctor: Is there an injury associated with this pain, ma'am?
Patient: I think it has to do with me lifting weights.
Doctor: Yes, that's common. Is this messing with your ability to work?
Patient: No, it's not really.
Doctor: What do you do for a living?
Patient: I'm a housekeeper, it's my profession.
Doctor: Are you having trouble sleeping at night?
Patient: Yes, it's not severe, but I'm having some trouble.
Doctor: With ten being the worst pain imaginable, how would you rate your pain today?
Patient: I'd say it's usually a two out of ten.
Doctor: When it's the worst, how would you rate it?
Patient: When that happens, I'd say it's a three or a four.
Doctor: Do you take any medicines for this pain?
Patient: Over the counter medications usually help the pain go away.
Doctor: Do you have any other complaints?
Patient: No, just this muscle pain.
Doctor: Do you have any loss of balance when you hold something with this arm?
Patient: No, my strength and everything is normal there.
Doctor: Do you have any signs of infection? That'd be anything like fever or chills, anything like that?
Patient: No, I don't have anything like that.

assistant: This is a 34-year-old African American female who comes today for routine followup. She has no acute complaints. She reports that she has a muscle sprain on her upper back from lifting. The patient is a housekeeper by profession. It does not impede her work in anyway. She just reports that it gives her some trouble sleeping at night, pain on 1 to 10 scale was about 2 and at worse it is 3 to 4 but relieved with over-the-counter medication. No other associated complaints. No neurological deficits or other specific problems. The patient denies any symptoms associated with opportunistic 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: PASTMEDICALHX

Dialogue:
Doctor: How can I help you today.
Patient: I have been having irregular periods.
Doctor: When was your last menstrual period?
Patient: My last period was on June first two thousand and four.
Doctor: Are you currently sexually active? Is there a possibility of pregnancy?
Patient: No! There is no possibility that I am pregnant. I have not had sex in two years.
Doctor: How old where you when you had your first menstrual period?
Patient: I was ten years old when I got my first period. My cycle has never been regular. It runs in my mom's side of the family.
Doctor: What is your family history of reproductive health conditions on your mom's side of the family?
Patient: My mom and my aunt have both had total hysterectomies.
Doctor: Is there any other personal medical history I should know about?
Patient: I see Doctor X Y Z Allen for my abnormal heart valve condition. I am on S B E prophylaxis. I have to limit my activity because of my heart condition.
Doctor: Do you avoid decongestants?
Patient: Yes.

assistant: She denies sexual activities since two years ago. Her last menstrual period was 06/01/2004. Her periods have been irregular. She started menarche at 10 years of age and she is still irregular and it runs in Mom's side of the family. Mom and maternal aunt have had total hysterectomies. She also is diagnosed with abnormal valve has to be on SBE prophylaxis, sees Dr. XYZ Allen. She avoids decongestants. She is limited on her activity secondary to her heart condition.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ROS

Dialogue:
Doctor: How have you been feeling? How is your leg feeling?
Patient: My right leg is in a lot of pain. The nurse just changed the bandage. I only have a rash where the bandage is.
Doctor: It looks like we have you taking Vicodin for the pain. Is the medication not helping?
Patient: The pain medication is horrible. I have been throwing up, off and on. I have been constipated since I have been here.
Doctor: I'll note that. Vomiting since February nineteen of two thousand seven. I am sorry to hear that. I will make a change to the medication and get you something for the constipation issue.
Patient: Thank you.
Doctor: Have you had any shortness of breath, chest pain or coughing up blood?
Patient: No.
Doctor: Any joint pain, headaches or rashes?
Patient: No. Just a rash where the bandages are like I said earlier. I also want to discuss this acne while I am here. I have had it for about two years. It's nothing big, just mild to moderate in severity.

assistant: He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication. He has had acne for about two years, which he describes as mild to moderate. He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you smoke, sir?
Patient: Well, I used to a long time ago, but I don't anymore.
Doctor: Good, what about alcohol, do you drink?
Patient: Well, my wife and I have a drink or two a day.

assistant: He has a very remote history of tobacco use. He has one to two alcoholic drinks per day. He is married.