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: Can you confirm your age for me, ma'am?
Patient: Absolutely, I'm sixty six now.
Doctor: Good, so it's been about five months since you last evaluation for type two diabetes and high blood pressure.
Patient: Yes, and I have a few other problems today, too.
Doctor: Sure, we can treat all of them. What seems to be the problem today?
Patient: I'm having some right shoulder pain.
Doctor: Can you remember an injury to this shoulder?
Patient: No, not that I can remember.
Doctor: What aggravates your symptoms?
Patient: It hurts when I move the shoulder.
Doctor: Do you have any weakness, numbness, or tingling?
Patient: No, I don't have any of that.
Doctor: Okay, back to diabetes, how has that been progressing?
Patient: Well, I can only check it in the morning, and it's usually less than one hundred.
Doctor: Have you been checking your blood sugar two hours after meals?
Patient: No, doctor, I haven't been. When I check them, it's normal though.
Doctor: Do you have any records to prove that?
Patient: No, I don't have that with me today.
Doctor: That's important, do you have any other issues or concerns today?
Patient: No, I can't think of anything.
Doctor: Okay. I'm looking at your charts, and I see you had a benign breast biopsy done on June eleventh two thousand four. Did you have a repeat done after six months like they asked?
Patient: No, I never had that done, I need to.

assistant: The patient is a 66-year-old female who presents to the clinic today for a five-month recheck on her type II diabetes mellitus, as well as hypertension. While here she had a couple of other issues as well. She stated that she has been having some right shoulder pain. She denies any injury but certain range of motion does cause it to hurt. No weakness, numbness or tingling. As far as her diabetes she states that she only checks her blood sugars in the morning and those have all been ranging less than 100. She has not been checking any two hours after meals. Her blood pressures when she does check them have been running normal as well but she does not have any record of these present with her. No other issues or concerns. Upon review of her chart it did show that she had a benign breast biopsy done back on 06/11/04 and was told to have a repeat mammogram in six months but she has never had that done so she is needing to have this done as well.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Do you mind giving me a run down of his past medical history? I want to make sure it's all in his chart.
Guest_family: Sure. I'll start with his surgeries. If I remember correctly, he had back surgery, a couple knee surgeries, and coronary artery bypass surgery with angioplasty.
Doctor: I see. When did he have these done?
Guest_family: I'd have to check, but I know he had back surgery in O nine. He has a history of high blood pressure and high cholesterol. He was recently diagnosed with B P H potentially linked to cancer. It's B P H, right? Or is it B H P?
Doctor: If it's his prostate, then B P H is correct.
Guest_family: Oh, he has high P S A levels, too. I think that's related to the prostate.
Doctor: Is he currently experiencing any symptoms?
Guest_family: He was complaining of pain earlier. He does have a history of fatigue, tiredness, and shortness of breath though. So far, he hasn't complained about the usual.

assistant: Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer. Symptoms of shortness of breath, fatigue, and tiredness.
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 long have you been living with diabetes, sir?
Patient: Oh, it's been about thirty five years now.
Doctor: How long have you been taking insulin for this?
Patient: Well, um, I've been taking insulin for about twenty years now.
Doctor: Do you have any major medical conditions that I should know about?
Patient: Yeah, um, prostate cancer.
Doctor: How were you treated for this?
Patient: I've had radiation. Oh, my P S A is zero point zero one, by the way.

assistant: The patient has been diabetic for 35 years, has been insulin-dependent for the last 20 years. He also has a history of prostate cancer, which was treated by radiation. He says his PSA is at 0.01.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: So, what stomach symptoms are you experiencing?
Patient: I feel an intense burning in my throat.
Doctor: When do you feel this?
Patient: It really hurts after eating food, especially junk food.
Doctor: That's pretty consistent with reflux disease.
Patient: Ah, yes.
Doctor: I got your survey results back as well, let's discuss them.
Patient: Absolutely, please, what does it show.
Doctor: According to your answers, it looks like you have depression as well.

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

user: Section: ROS

Dialogue:
Doctor: Any difficulty in swallowing?
Patient: No.
Doctor: Any nausea, vomiting or blood in your vomit?
Patient: No, no vomit at all. No problem there.
Doctor: Okay, any stomach pain?
Patient: No.
Doctor: Okay.

assistant: GASTROINTESTINAL: Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative 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: PASTMEDICALHX

Dialogue:
Doctor: Hello, ma'am. How are you feeling today?
Patient: I'm sad and depressed.
Doctor: I'm sorry to hear that. Why do you feel that way?
Patient: My cancer came back.

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

user: Section: DIAGNOSIS

Dialogue:
Doctor: What's going on with you? What brings you here today?
Patient: I am having loose watery stools for more than two weeks now. I feel very lethargic. I also have pain in my tummy.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are you a smoker?
Patient: I used to smoke. I quit in nineteen sixty eight.
Doctor: Excellent! Have you weighed your self recently?
Patient: I weighed myself this morning. I am at one hundred and eighty three pounds.
Doctor: And how tall are you?
Patient: I used to be five foot ten but I think I have been shrinking.
Doctor: That is definitely a possibility. We do shrink as we go through life. I can have the nurse get your height after we do your exam.
Patient: Okay.

assistant: He quit smoking in 1968. His current weight is 183 pounds. His tallest height is 5 feet 10 inches.
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: Welcome to the clinic, sir.
Patient: Thank you.
Doctor: Let us start with your medical history.
Patient: I used to have seizures, but they have stopped now.
Doctor: Was there a cause of the seizures?
Patient: About seven years ago I had a traumatic stroke. They told me I had bleeding in the brain. After the stroke I was left with this weakness on my right side.
Doctor: What part of your body is affected by the weakness?
Patient: My arm, hand, and my face.
Doctor: Do you have any other health problems?
Patient: My liver is falling. It is because of all the alcohol that I have consumed over the years. I am not drinking anymore.
Doctor: Are you being treated for your liver disfunctions?
Patient: No. I just stopped drinking. I think I have diabetes.
Doctor: What makes you feel like you have diabetes?
Patient: I have been really thirsty, and I have been having numbness and tingling in my feet.
Doctor: Oh okay. We can definitely do some test today to find out if you are diabetic or not.

assistant: 1. Liver cirrhosis caused by alcohol. This is per the patient. 2. He thinks he is diabetic. 3. History of intracranial hemorrhage. He said it was subdural hematoma. This was traumatic and happened seven years ago leaving him with the right-sided hemiparesis. 4. He said he had a seizure back then, but he does not have seizures now.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Hi miss. How old are you?
Patient: I am sixteen.
Doctor: What race do you identify as?
Patient: White.
Doctor: Are you okay? You have a headache?
Patient: No I have a really bad migraine.
Doctor: Okay can you point to where you are feeling it the most?
Patient: Here, since Monday.
Doctor: Okay so mostly on the right frontal side and it's been forty eight hours now?
Patient: Yes, I am feeling a lot of pressure.
Doctor: I can understand the discomfort. Is it continuous or throbbing?
Patient: It is throbbing.
Doctor: On the scale of one to ten, ten being the worst, how would you rate it?
Patient: Nine or more.
Doctor: Have you ever experienced similar symptoms in the past?
Patient: No I haven't.
Doctor: Did you hit your head buy any chance?
Patient: No no.
Doctor: Okay can you tell me if you have any fever or chills, congestion, cough cold like symptoms?
Patient: No.
Doctor: Any nausea, vomiting, diarrhea or trauma anywhere?
Patient: No nothing like that.
Doctor: Anything from head to toe?
Patient: No everything else is fine.

assistant: This is a 16-year-old white female who presents here to the emergency department in a private auto with her mother for evaluation of headache. She indicates intense constant right frontal headache, persistent since onset early on Monday, now more than 48 hours ago. Indicates pressure type of discomfort with throbbing component. It is as high as a 9 on a 0 to 10 scale of intensity. She denies having had similar discomfort in the past. Denies any trauma. Review of systems: No fever or chills. No sinus congestion or nasal drainage. No cough or cold symptoms. No head trauma. Mild nausea. No vomiting or diarrhea. Other systems reviewed and are negative.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: EXAM

Dialogue:
Doctor: Has the patient signed a do not resuscitate order?
Guest_family: Yes, she has.
Doctor: Does she have a healthcare proxy or durable power of attorney?
Guest_family: Yes, she has both.

assistant: CODE STATUS: DNR, healthcare proxy, durable power of attorney.
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: How are you doing today?
Patient: I have a long history of lung disease. COPD to be exact. Recently, I was experiencing a lot of coughing and shortness of breath even on walking from one room to another. All the time I felt sleepy, tired, or confused.
Doctor: How is it now?
Patient: It is getting better.
Doctor: What else?
Patient: I was also diagnosed with pneumonia; I was on trip and there they found it. It is also getting a lot better now, but doctor said to continue taking oxygen for some more time.
Doctor: Oh wow!
Patient: With everything going on, I felt weak and tired and it looks like I have lost all my strength and muscle.
Patient: I also felt very instable and had a fall. I did not call for any assistance but now I think I should have called someone. Everyone including my family and nurses all tell me all the time to call for assistance. I was just being stubborn and hurt myself.
Doctor: Did you use a wheelchair?
Patient: No.
Doctor: You know I would agree with everyone else; you should call for assistance if you need help like getting out of bed or need to use the restroom.

assistant: 1. Acute on chronic COPD exacerbation. 2. Community acquired pneumonia both resolving. However, she may need home O2 for a short period of time. 3. Generalized weakness and deconditioning secondary to the above. Also sustained a fall secondary to instability and not using her walker or calling for assistance. The patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed.
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: Were there any medical issues in the past?
Patient: Oh, I have a list. I have asthma and sinus issues. I also had hives at some point and psoriasis.
Doctor: How about allergies?
Patient: I don't know of any.

assistant: The patient has asthma, sinus, hives, and history of psoriasis. No known drug allergies.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Do you use tobacco products, alcohol, or recreational drugs, miss?
Patient: I have a drink every once and a while.
Doctor: How many drinks do you consume in a week?
Patient: I don't even drink that often. I probably have one drink per month.
Doctor: Are you married?
Patient: I was engaged but that is not happening anymore. It is a long story.
Doctor: I am sorry the hear that. What do you do for work?
Patient: I am a metal grinder.

assistant: works as a metal grinder and was engaged to be married. She denied any tobacco or illicit drug use. She consumed 1 alcoholic drink per month.
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 that you're eighteen, I have a big question to ask you. Do you smoke?
Patient: Never have, never will.
Doctor: That's what I like to hear. You have a good head on your shoulders, bud.
Patient: Thanks. I'd like to think so, too. I have some friends who smoke weed, but stay clear of tobacco.

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: Have you ever been diagnosed with any illnesses?
Patient: No, I do not have any diseases.
Doctor: How about any issues with B P, thyroid, diabetes?
Patient: Nope none.

assistant: No significant past medical 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: FAM/SOCHX

Dialogue:
Guest_clinician: Any history of drug or alcohol use?
Doctor: He was a former smoker and tested positive for cocaine during his last visit in January O eight.

assistant: He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.
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: I just quickly wanted to check few things, let's go over them together?
Patient: Sure.
Doctor: Any heart condition like heart failure or anything?
Patient: No.
Doctor: Any heart catheterization?
Patient: Um, no.
Doctor: Any history of chest pain, palpitation, or irregular heartbeat?
Patient: No.
Doctor: Do you have high blood pressure?
Patient: No.
Doctor: Any history of high cholesterol?
Patient: No.
Doctor: Any excessive or abnormal sweating?
Patient: Not really, no.
Doctor: Any stress test or heart tests done recently?
Patient: No.
Doctor: Okay, thank you for answering these questions.
Patient: No problem.

assistant: CARDIOVASCULAR: No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.
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 Sherry, how are you doing today?
Patient: I have seen worse days.
Doctor: Ha, I will take that as a positive answer then. I have my resident here with me, Doctor Helm, she will be representing your case today.
Guest_clinician: Hello.
Patient: Hello Doctor Helm.
Doctor: Doctor Helm.
Guest_clinician: The patient is a sixty one year old female. She was diagnosed with non small cell lung cancer stage one A in the upper right lobe. She was treated with CyberKnife and the treatment was completed one month ago. This is her first visit after the CyberKnife treatment.
Doctor: Thank you Doctor Helm. So, Miss Sherry, how are you doing after the treatment?
Patient: I feel nauseous.
Doctor: How would you define it mild, moderate, or severe?
Patient: I would say mild.
Doctor: What about vomiting?
Patient: No, only nausea is there. If I try to take deep breaths, then I still have pain.
Doctor: How is your dysphagia? Are you able to swallow and eat your food and drink now?
Patient: It has been better now. I won't say I am all good but as I said I have seen the worst days.
Doctor: Is there any heartburn or rash?
Patient: No.
Doctor: Are you coughing up blood, or just cough?
Patient: No, none of them.
Doctor: Let me exam for any rib pain, okay?
Patient: Okay.
Doctor: Any pain if I touch you here or here?
Patient: No.

assistant: The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit. Since undergoing CyberKnife treatment, she has had low-level nausea without vomiting. She continues to have pain with deep inspiration and resolving dysphagia. She has no heartburn, cough, hemoptysis, rash, or palpable rib 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: Let's talk about your family history. Did anyone in your family have any medical issues that you were aware of?
Patient: I don't think so. My family has been pretty healthy. Both my parents died of old age.
Doctor: What about your siblings? Any kind of thyroid issue or diabetes or blood pressure issue there?
Patient: I have one older brother. He's into weightlifting and all. I would say he's pretty healthy.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Can you tell me more about your parents, please? How are they doing?
Patient: Thank you for asking, they're both doing very well. They're very healthy.
Doctor: That's great to hear. How old are they?
Patient: My mom is fifty, and my dad is forty.
Doctor: Wonderful, do you have any siblings?
Patient: Yeah, I have two sisters, one is a half sister, and the other we have the same mom and dad.
Doctor: How old are they?
Patient: My half sister and I have the same mom, and she's thirty four. My other sister is ten.
Doctor: Do they have any history of medical conditions that you know about?
Patient: My half sister, um, no. My other sister has had some yeast infections.

assistant: Mother is 50 and healthy. Dad is 40 and healthy. Half-sister, age 34, is healthy. She has a sister who is age 10 who has some yeast infections.
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, what brings you here today? Also, please confirm your age for the records.
Patient: I am seventy years old. I am here for nothing particular but I just have discomfort on the right side.
Doctor: We did electromyography study. This was to assess the health of muscles and the nerves in your body. When did you first notice this discomfort?
Patient: About five years ago. After my stroke. I've been to a neurologist before.
Doctor: Yeah, I can see that you have taken different kinds of medications, but nothing seems to help you.
Patient: That sounds right. Nothing seems to help me to get rid of this discomfort.
Doctor: How often do you check your sugar levels?
Patient: I do it at home. Mainly two to three times a day. I increase or decrease the amount of insulin that I take based on my numbers.
Doctor: Don't you consult anyone before doing that?
Patient: It's been so many years now. I do it all by myself.
Doctor: We did reevaluations of your symptoms. It turned out to be all negative. Do you smoke?
Patient: I used to chew tobacco a lot and then there were drinks. I used to drink at least half a bottle of single malt in one night. I quit everything five years ago after my stroke.

assistant: This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see a neurologist. We have tried different medications and it just does not seem to help. He checks his blood sugars at home two to three times a day. He kind of adjusts his own insulin himself. Re-evaluation of symptoms is essentially negative. He has a past history of heavy tobacco and alcohol usage.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: ASSESSMENT

Dialogue:
Doctor: It is nice to see you again, miss. We are following up on a few things today. How is your arm feeling?
Patient: My arm is all better. It is not in pain at all anymore.
Doctor: How has your mood been? Are you feeling any relief from your symptoms since you have been on the Lexapro?
Patient: It's helping a little bit.
Doctor: How much Lexapro are you taking now?
Patient: I am taking ten M G.
Doctor: How long have you been taking the full dosage?
Patient: About a week ago. I don't take it every day. I don't feel like I need it some days.
Doctor: I want you to take the full dosage every day. This might be why you have not had much relief with your symptoms yet.
Patient: Okay.
Doctor: Your hands are a little shaky. Is this a normal occurrence for you?
Patient: I didn't even notice.
Doctor: It is very subtle. We will keep an eye on it for now. Your blood pressure is a little better today. Have you experienced any worsening joint or bone pain? I want to check on your osteoporosis and osteoarthritis.
Patient: No.

assistant: 1. Hypertension, better reading today. 2. Right arm symptoms, resolved. 3. Depression probably somewhat improved with Lexapro and she will just continue that. She only got up to the full dose 10 mg pill about a week ago and apparently some days does not need to take it. 4. Perhaps a very subtle tremor. I will just watch that. 5. Osteoporosis. 6. 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: GENHX

Dialogue:
Doctor: How long it has been since these psychotic periods are going off and on?
Patient: It has been around twenty years.
Doctor: So, you were taking Clozaril and some other medications?
Patient: Yes.
Doctor: Were you feeling better with them, sir?
Patient: Yes. It was better for some years.
Doctor: These antipsychotics, they were good on you, right?
Patient: They were at times, but eventually there was a new episode.

assistant: As mentioned before, this patient has been psychotic off and on for about 20 years now. He has had years in which he did better on Clozaril and also his other medications. With typical anti-psychotics, he has done well at times, but he eventually gets another psychotic bout.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Does anyone in your family ever have any neurological disorder?
Patient: Not anything specific but, many of my family members had lazy eyes.
Doctor: Who is in your family?
Patient: My parents and my two little sisters.
Doctor: How old are your sisters?
Patient: One is nine, another one is five.
Doctor: How are they both health wise?
Patient: They both are healthy.

assistant: Many family members with "lazy eye." No other neurologic diseases declared. 9 and 5 year old sisters who are healthy.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTSURGICAL

Dialogue:
Doctor: I have their surgical history if you'd like to go over it.
Guest_clinician: Go ahead.
Doctor: So they had an exploratory laparotomy in nineteen sixty seven.
Guest_clinician: Okay.
Doctor: They had a number of surgeries in nineteen seventy five, which include an L five S one lumbar laminectomy, anal fissure surgery, tonsillectomy, and adenoidectomy.
Guest_clinician: Got it. Any complications that you know of?
Doctor: None were mentioned by the patient or their spouse.

assistant: L5-S1 lumbar laminectomy in 1975, exploratory laparotomy in 1967, tonsillectomy and adenoidectomy, and anal fissure surgery in 1975.
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 is your foot feeling?
Patient: It feels good.
Doctor: Any pain or discomfort when you walk around on it?
Patient: No. I am good doc.

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: FAM/SOCHX

Dialogue:
Doctor: Are you married?
Patient: Yes, for almost twenty two years now.
Doctor: That is amazing! And are you working?
Patient: Ah yes, I drive a delivery truck in the town.
Doctor: Okay. So, tell me do you smoke or drink? Yes, I do both.
Doctor: And how much would you say you smoke per day?
Patient: I smoke about two packs a day.
Doctor: Hm, how much do you drink?
Patient: I drink three, oh wait, I drink two beers every day.
Doctor: And do you do any drugs like coke or anything?
Patient: No.

assistant: The patient is married. He works as a truck driver and he drives in town. He smokes two packs a day and he has two beers a day he says, but not consuming illegal drugs.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are you married?
Patient: No sir, I'm happily single.
Doctor: Where do you work?
Patient: I am a press worker, I work in a newspaper printing.
Doctor: Do you smoke? Have you ever taken any Illicit drug?
Patient: No, none of them.
Doctor: What about alcohol?
Patient: I don't take any now. I was a heavy drinker, but I quit in the seventies.

assistant: Single. Works as a newpaper printing press worker. Denies tobacco, ETOH or illicit drug use, but admits he was a heavy drinker until the last 1970s when he quit.
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 like any diabetes or high blood pressure or any heart disease?
Patient: No, I don't remember any such thing.
Doctor: How about any surgeries in the past?
Patient: No. No surgeries at all.

assistant: Otherwise nondescript as is the past surgical 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: GENHX

Dialogue:
Doctor: Good morning, young lady, how old are you?
Patient: Good morning, doctor. I'm thirteen.
Doctor: Good, and what seems to be the problem today? Mom, can you explain for me?
Guest_family: Well, if you look, doctor, her back posture is very rounded.
Doctor: I think, it's rounding about the thoracic spine. Is there a family history of this problem?
Guest_family: Yes, on my side, my aunt and grandfather had, um, kyphosis.
Doctor: Yes, that's what this is. This is thoracic kyphosis to be specific. Has she seen another doctor for this?
Guest_family: Yes, we saw another orthopedist.
Doctor: What did they recommend?
Guest_family: They recommended we come in for further observation, so we're here for a second opinion.
Doctor: Good, is there any back pain, numbness or tingling?
Patient: No, I don't have any of that.
Doctor: Is there any weakness, numbness or tingling in your legs and arms, my dear?
Patient: No, I'm very strong, especially for my age.
Doctor: Are you going to the bathroom with no problem?
Patient: Yes, doctor, everything is regular there.

assistant: The patient is a 13-year-old new patient is here for evaluation of thoracic kyphosis. The patient has a family history in a maternal aunt and grandfather of kyphosis. She was noted by her parents to have round back posture. They have previously seen another orthopedist who recommended observation at this time. She is here for a second opinion in regards to kyphosis. The patient denies any pain in her back or any numbness, tingling, or weakness in her upper or lower extremities. No problems with her bowels or bladder.
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: No, I am not allergic to anything.
Doctor: Okay so no drug allergies.
Patient: Yeah.

assistant: No known drug allergies.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: Are you married, ma'am.
Patient: Yes, to my husband, I can't even remember how long my husband and I have been married.
Doctor: That's wonderful. Do you drink or smoke?
Patient: Absolutely not, I've never have used that stuff.

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

user: Section: FAM/SOCHX

Dialogue:
Doctor: Uh let's see here. Are there any diseases that run in your-
Patient: Family?
Doctor: Yes.
Patient: Nope.

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

user: Section: GENHX

Dialogue:
Doctor: What happened to you? How did you get involved in this accident?
Patient: I was just trying to adjust cable that my brother's dog was tied to. All of a sudden, he attacked me out of nowhere. The injury to my leg is V shaped and the V is pointing towards my foot.
Doctor: What kind of dog?
Patient: German shepherd. But he is up to date on his shots, and he is completely healthy.
Patient: He bit me on my foot, and it looks like his teeth went into my skin. I went to my P C P.
Doctor: What did you do there?
Patient: They cleaned the wound and did some bandage along with it he gave me a tetanus shot.
Doctor: And he sent you to us?
Patient: Yes.
Doctor: Okay let me examine your wound.
Patient: Sure!
Doctor: It looks like there is a flap injury developed after puncture wound. It seems like a centimeter long and viable. How old are you sir? And what ethnicity do you identify with?
Patient: White male. I am fifty years old. Is my right leg going to be okay?
Doctor: The skin looks viable. We can save the tissue.

assistant: This 50-year-old white male earlier this afternoon was attempting to adjust a cable that a dog was tied to. Dog was a German shepherd, it belonged to his brother, and the dog spontaneously attacked him. He sustained a bite to his right lower leg. Apparently, according to the patient, the dog is well known and is up-to-date on his shots and they wanted to confirm that. The dog has given no prior history of any reason to believe he is not a healthy dog. The patient himself developed a puncture wound with a flap injury. The patient has a flap wound also below the puncture wound, a V-shaped flap, which is pointing towards the foot. It appears to be viable. The wound is open about may be roughly a centimeter in the inside of the flap. He was seen by his medical primary care physician and was given a tetanus shot and the wound was cleaned and wrapped, and then he was referred to us for further assessment.
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 aware of any family medical history?
Patient: Nope. Both of my parents, they died of old age. They were in their eighties. I cannot remember of any other medical issue in any of my relatives.
Doctor: What about memory loss or stroke or high blood pressure, diabetes, or any other kind of mental illness?
Patient: Nope.
Doctor: Anyone sick in your family out of these things?
Patient: Nope.
Doctor: Do you have kids?
Patient: Yeah, I have five children and they all are doing well in their life.

assistant: Father and mother died in their 80's of "old age." There was no history of dementing illness, stroke, HTN, DM, or other neurological disease in her family. She has 5 children who were alive and well.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTMEDICALHX

Dialogue:
Doctor: Do you have any significant medical conditions in your history that I should know about?
Patient: What, like high blood pressure?
Doctor: Well, it could be anything from high blood pressure, to depression, to something as serious as cancer.
Patient: Oh, no, I don't have anything like that, at least not that I know if.

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: Hi! How are you two doing today?
Guest_family: We are doing good. I am tired today.
Doctor: Our records show that he is up to date on all of his two month old immunizations.
Guest_family: That is right! He had his shots the last time we were here.
Doctor: Does he have any health conditions or difficulties during childbirth?
Guest_family: Nope. He is healthy.

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

user: Section: GENHX

Dialogue:
Doctor: Hello! How are you all today?
Guest_family: Not good. We are really worried about our daughter.
Doctor: What happened?
Guest_family: I turned my back for one second and I saw her under the counter in the cabinet. We have childproofing on that cabinet. I don't know how she got it open. I pulled her out from the cabinet, and she had the bottle of ant bait in her hands. She had spilled the entire bottle all over her. She had the liquid on her hands. I don't know if she drank any of it or put her hands in her mouth.
Doctor: Do you know what the ant bait was called?
Guest_family: No. I know it was the kind with Borax in it.
Doctor: Do you know how big the container was?
Guest_family: It was an eleven M L bottle. I am not sure if that stuff is toxic or not?
Doctor: How old is she?
Guest_family: She is fourteen months.
Doctor: Have you noticed and strange behavior or vomiting?
Guest_family: No.

assistant: This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it. It had 11 mL of this fluid in it. She spilled it on her, had it on her hands. Parents were not sure whether she ingested any of it. So, they brought her in for evaluation. They did not note any symptoms of any type.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: PASTSURGICAL

Dialogue:
Doctor: Hello. Are you ready for your surgery today?
Patient: I'm ready as can be. This isn't my first rodeo.
Doctor: I see. Have you had surgeries before?
Patient: Yeah, I have. I think it's in my report that you have with you.
Doctor: You're right. It says here you've had some stripping of veins in your legs, a tonsillectomy, and a adenoidectomy.

assistant: Lower extremity vein stripping, tonsillectomy and adenoidectomy.
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 she married?
Guest_family: Um no, she's divorced.
Doctor: Any history of tobacco, alcohol or drug use?
Guest_family: I think she used to drink? But I'm not positive.

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

user: Section: DIAGNOSIS

Dialogue:
Doctor: I'd like to get her in to see you sometime next week for her enlarged thyroid.
Guest_clinician: Is she symptomatic?
Doctor: Yes, she's experiencing increased difficulty swallowing. She's also reporting throat tightness on an off.
Guest_clinician: What's her medical record number?

assistant: Symptomatic thyroid goiter.
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! How are you today?
Patient: I am doing well. I start a new job on Monday. I have been unemployed for about a year now. It is going to be nice to get back to work.
Doctor: Congratulations. Do you use tobacco products, drink alcohol or recreational drugs?
Patient: I used to smoke a little bit, but I quit ten years ago.
Doctor: Great!
Patient: I don't drink or do drugs.

assistant: He was unemployed and denied any alcohol or drug use. He was a prior 'mild' smoker, but quit 10 years previous.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: FAM/SOCHX

Dialogue:
Doctor: So, tell me about your family's medical history.
Patient: Hm, my mother passed away due to cancer.
Doctor: Oh, what type?
Patient: Actually, I don't know that.
Doctor: Okay.
Patient: And my dad died due to heart attack.
Doctor: Oh.
Patient: Yeah.
Doctor: Okay, I don't see your vaccination record here, do you have it?
Patient: No, I don't have it. I moved here from a different country a long time ago with barely anything. I don't have any medical records from my past.
Doctor: I see.

assistant: Mother died of cancer, unknown type. Dad died of an MI. VACCINATION STATUS: Unknown.
system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Welcome back to the clinic, Miss A B C.
Patient: Thank you.
Doctor: It looks like we last saw you June twenty first, this year. Doctor X and Y referred you for the evaluation of your pinched nerve in the C six regain on the left side. I also see that we are following up on the significant rotator cuff tear on the left side. Did you get scheduled for the surgery with Doctor Yen yet?
Patient: Yes. I believe the surgery is scheduled for July twentieth.
Doctor: How is your shoulder feeling?
Patient: My shoulder is the same. I am still in a significant amount of pain.
Doctor: I am sorry to hear that. Your surgery is coming up soon and that should help.
Patient: I hope so.
Doctor: We are also following up the pinched nerve in your upper left extremity C six. How are you feeling?
Patient: I have had some pain starting in that same spot, and it goes down the left arm into my wrist.
Doctor: Have you had any weakness associated with your upper extremities on the left side?
Patient: It is mild and it is about the same as the last time.
Doctor: Is it about the same as the last time you were here? We have it noted in the last note that it was mild as well.
Patient: Yes. It has been the same.
Doctor: Any weakness or symptoms on the right side?
Patient: No, not really.
Doctor: Any difficulty with mobility or moving around on either side?
Patient: No.
Doctor: Have you been experiencing any bowel or, bladder dysfunction.
Patient: No.
Doctor: I see in the chart for our last visit, I only had a report of a prior cervical spine M R I. I don't have any recent images. I going to refer you for a cervical spine M R I. Are you able to get the imaging done today and I will have you return to the clinic at the end of today?
Patient: Yes. I can do that. I took the whole day off of work today.
Doctor: Great! I will put the order in right now.

assistant: Ms. ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy. I had last seen her on 06/21/07. At that time, she had been referred to me Dr. X and Dr. Y for evaluation of her left-sided C6 radiculopathy. She also had a significant rotator cuff tear and is currently being evaluated for left-sided rotator cuff repair surgery, I believe on, approximately 07/20/07. At our last visit, I only had a report of her prior cervical spine MRI. I did not have any recent images. I referred her for cervical spine MRI and she returns today. She states that her symptoms are unchanged. She continues to have significant left-sided shoulder pain for which she is being evaluated and is scheduled for surgery with Dr. Y. She also has a second component of pain, which radiates down the left arm in a C6 distribution to the level of the wrist. She has some associated minimal weakness described in detail in our prior office note. No significant right upper extremity symptoms. No bowel, bladder dysfunction. No difficulty with ambulation.
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: Hey, how is the patient doing?
Guest_clinician: I actually don't know, I was not able to examine him. He is having special procedures done for the past two hours for some medical management.
Doctor: Oh, I see.

assistant: Medical management. The patient has been in special procedures now for over 2 hours and I am unable to examine.
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_family: So, you mean it is something simple?
Doctor: Yes, it is probably sinus infection and then cough secondary to that infection.
Guest_family: Will that be treatable?
Doctor: Yes, it is.
Guest_family: Okay nice.

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

user: Section: DIAGNOSIS

Dialogue:
Doctor: You have an infection that has become septic. We are going to have to start you on intravenous antibiotics.
Patient: Okay.
Doctor: We also need to address the blood clotting. I am going to give you an anticoagulant to prevent any further clotting issues. Do you have any questions?
Patient: No.

assistant: 1. Disseminated intravascular coagulation. 2. Streptococcal pneumonia with sepsis.