🩺 Record Detail
Patient Info
Transcript
[SYSTEM INSTRUCTION: You are a medical AI scribe applying an Instruction Layer. 1. Identify any 'Meta Directions' (formatting instructions, corrections, ignore-rules, or section-creation rules) dictated by the doctor. 2. Do NOT treat Meta Directions as clinical facts. Instead, use them as strict rules to shape the final note. 3. Apply formatting instructions (e.g., bullet points, conciseness). 4. Apply correction instructions (e.g., overriding a pain score or symptom). If there are conflicting facts/instructions, follow the LATEST applicable Meta Direction. 5. Apply ignore instructions (e.g., omit specific brand names). 6. Move information to the section explicitly requested. If requested to place information in 'Procedure', 'Internal Notes', 'Orders/Follow-up', 'Coding', etc., you MUST dynamically create those sections in your output if they aren't in the standard template. 7. Do not invent unsupported clinical information. However, you MUST intelligently incorporate important and relevant clinical information explicitly provided in the PATIENT CONTEXT into the appropriate sections of the selected template, even if the doctor did not mention that information in the current transcript. Keep transcript-derived information accurate and clearly avoid unsupported assumptions or fabricated details. 8. Output all detected Meta Directions as a JSON list of strings within a [[META_DIRECTIONS_START]]...[[META_DIRECTIONS_END]] block at the very end of your response. 9. If the transcript explicitly states 'The clinical notes are' (or similar), you MUST use ONLY that explicitly dictated content to fully fill out the clinical note sections. Additionally, if explicit dictation for CLINICAL NOTES is detected, you MUST append the following exact block to the very end of your response: [[SUGGESTED_BY_DOCTOR_START]] <exact dictated text for the clinical notes> [[SUGGESTED_BY_DOCTOR_END]] The text inside the delimiters MUST be a VERBATIM, character-for-character copy from the transcript. Do NOT fix typos, do NOT reformat, and do NOT correct medical terms. Do NOT output 'Suggested by Doctor:' in the main text. Do NOT extract dictated text for other sections like summary, orders, or coding.] [CURRENT ENCOUNTER TRANSCRIPT] Clinician: The psychologist conducting thing we discuss is confidential within our clinical team with standard exceptions around immediate safety. Into our session today. Patient: My GP referred me to Kynarc after I started having sudden panic attacks and severe insomnia over the last three months. Clinician: Thank you for sharing the ultimate first step during these panic episodes. Patient: It usually happens before major presentations at work. It's pounding intensely. My chest tightens up so I feel like I can't catch my breath and my hands get cold and clammy. I feel dizzy and detached like I'm watching myself from outside my body. Clinician: And to race through your mind during those physical searches. Patient: I get flooded with catastrophic thoughts. What if I collapse right here? It feels so overwhelming. Clinician: Escaping provides enforcement. Dangerous. Reinforcing the fear of health and safety. Any chronic suicide or self-harm. Patient: Risk with zero suicidal intent or self-harm.
Clinical Notes
Clinical Note
Subjective
The patient reports experiencing sudden panic attacks and severe insomnia over the last three months, which prompted a referral from their GP to Kynarc. The panic attacks typically occur before major presentations at work. During these episodes, the patient experiences intense pounding in the chest, difficulty breathing, cold and clammy hands, dizziness, and a sense of detachment. The patient also experiences catastrophic thoughts, such as the fear of collapsing. There is no suicidal intent or self-harm risk reported.
Objective
The patient appears to be experiencing symptoms consistent with panic attacks, including physical symptoms such as chest tightness, cold and clammy hands, and dizziness.
Assessment
The symptoms described by the patient are indicative of panic disorder, particularly triggered by work-related stressors. The absence of suicidal intent or self-harm is noted.
Plan
Further psychological evaluation and therapy sessions to address panic disorder symptoms and develop coping strategies for stress management. Consideration of medication may be discussed in future sessions if symptoms persist or worsen.
[[META_DIRECTIONS_START]] [] [[META_DIRECTIONS_END]]