🩺 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. Preserve existing normal dictation behavior. 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.] [TRANSCRIPT] [PATIENT CONTEXT] John Smith is an established patient with a history of a previous routine dental cleaning approximately 8 months ago. At that visit, no urgent dental treatment was required. He previously reported occasional gum bleeding during brushing and was advised to maintain regular brushing and flossing. A previous dental examination documented an old filling on an upper right molar, which was stable at that time. The patient has no previously documented history of root canal treatment or tooth extraction. Doctor: Is it hard when you bite down on hot food? Patient: Yes, it throbs a bit after I eat something hard or crunchy. Doctor: On a scale of 1 to 10, how would you rate the pain? Patient: It's about a 6 when I drink something cold, but normally it's just a dull ache, maybe a 3.
Clinical Notes
Clinical Note
Subjective
John Smith, an established patient, reports experiencing throbbing pain after consuming hard or crunchy foods. He rates the pain as a 6 out of 10 when drinking something cold, and generally describes it as a dull ache, rated at a 3 out of 10. He has a history of occasional gum bleeding during brushing.
Objective
The patient has a stable old filling on an upper right molar. There is no documented history of root canal treatment or tooth extraction.
Assessment
The patient presents with dental pain exacerbated by hot and cold stimuli, likely related to the old filling on the upper right molar.
Plan
Recommend further evaluation of the upper right molar to assess the need for potential dental treatment. Advise the patient to continue regular brushing and flossing to manage gum health.
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