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.]

[PATIENT CONTEXT]
[PATIENT DEMOGRAPHICS & IDENTIFIERS]
Patient Name: Cameron Vance
DOB: 1984-07-14 (Age: 41) | Gender: Female | MRN: PT-84920-PSY
Provider: Dr. Robert Mitchell, PhD (Clinical Psychologist / Psychotherapist)
Service: Adult Outpatient Mental Health & Neurodevelopmental Follow-up
[CHIEF COMPLAINT & PRESENTING PROBLEM]
Patient presents for follow-up psychotherapy and medication monitoring. Reports chronic
executive dysfunction, low motivation, avoidance behaviors, and episodic depressive slumps
exacerbated by seasonal factors ("Blue Monday") and severe psychosocial stressors (childcare
demands, housing insecurity, and pending litigation).
[CURRENT MEDICATIONS & RECONCILIATION]
1. Adderall IR (Dextroamphetamine-Amphetamine) 20 mg PO BID (Morning & Early Afternoon)
- Indication: Attention-Deficit/Hyperactivity Disorder (ADHD, Combined Type).
- Adherence: Intermittent/Variable. Patient acknowledges self-directed omission of doses
when feeling unmotivated or actively wanting to avoid daily responsibilities. Noted immediate
positive response in alertness, executive initiation, and cognitive focus upon resumption.
2. Melatonin 5 mg PO QHS PRN for initial insomnia.
3. Multivitamin 1 tablet PO daily.
[ALLERGIES & INTOLERANCES]
- NKDA (No Known Drug Allergies).
- Food Intolerances: Reports delayed gastric distress, nocturnal reflux, and morning emesis
following heavy, high-sodium, or high-fat meals (e.g., late-night takeout).
[PAST PSYCHIATRIC HISTORY & DIAGNOSES]
1. Attention-Deficit/Hyperactivity Disorder (ADHD), Combined Presentation (DSM-5 314.01 /
ICD-10 F90.2)
- Baseline ASRS-v1.1 score: 19/24 (High symptom burden: task paralysis, verbal
impulsivity/interruptions during discourse, disorganization).
2. Major Depressive Disorder, Recurrent, Moderate, without psychotic features (ICD-10 F33.1)
- Manifested as lethargy, vegetative couch-bound days, feelings of worthlessness, low
self-efficacy, and severe neglect of domestic tasks (e.g., 2+ weeks of neglected laundry).
3. Generalized Anxiety & Avoidant Coping Tendencies
- Tendency toward cognitive distortions: catastrophizing, mind-reading, and perceived
helplessness ("fantasy of complete helplessness" when faced with novel mechanical or crafting
tasks).
[PAST MEDICAL & SURGICAL HISTORY]
- Gastroesophageal Reflux Disease (GERD) / Functional Dyspepsia (diet-related).
- Mild tension-type headaches secondary to ocular fatigue and dehydration.
- Past surgical: Uncomplicated appendectomy (age 19). No chronic cardiovascular, pulmonary,
or metabolic disease.

[SUBSTANCE USE HISTORY]
- Alcohol: Social/weekend consumption (2–4 drinks intermittently); reports susceptibility to
next-day dehydration and heightened depressive lethargy post-drinking.
- Tobacco / Nicotine: Denies.
- Cannabis / Illicit Substances: Denies.
- Caffeine: Moderate (2 cups of black coffee daily).
[PSYCHOSOCIAL, OCCUPATIONAL & FAMILY HISTORY]
- Marital & Relationship: Separated/co-parenting with former partner Jess. Chronic interpersonal
strain surrounding shared finances and real estate transitions.
- Dependents:
- Son: Ian (elementary school age; involved in Cub Scouts / Pinewood Derby; patient
experiences high parenting anxiety and fear of disappointing him).
- Daughter: Lucille (toddler; partner currently applying for preschool subsidies/aid).
- Housing / Financial Stress: Multi-family property currently facing foreclosure or short-sale
proceedings; negotiating separate apartment lease with target rent of $1,200/month.
- Legal & Occupational Stress: Employed in real estate title closings and settlements. Currently
entangled in complex condo association litigation involving hostile trustee affidavits,
unauthorized disclosures to defendants, and conflicting court dates (upcoming trial date conflict
on Tuesday the 29th).
[LONGITUDINAL CLINICAL PROGRESS & PAST ENCOUNTERS]
- Visit Date: 2026-01-08 (Individual Psychotherapy - 50 Min)
- Subjective: Discussed difficulty maintaining work routines post-holiday break. Reported
feeling scattered and overwhelmed by backlog of closings.
- Objective: ASRS score 18. Mood dysphoric, affect blunted but reactive.
- Assessment: ADHD symptoms prominent under unstructured conditions. Reinforce
behavioral anchors and scheduled timers.
- Plan: Continue Adderall 20 mg BID. Introduce task batching for professional emails.
- Visit Date: 2025-12-18 (Medication Review & Psychotherapy - 45 Min)
- Subjective: Patient reported stable focus during mornings, but late afternoon fatigue.
Complained of conflict with Jess regarding holiday visitation.
- Objective: Vital signs within normal limits (BP 122/78, HR 74). Speech normal rate, no formal
thought disorder.
- Plan: Re-affirmed boundary-setting strategies. Maintain current Adderall dosage.
[SAFETY & RISK ASSESSMENT]
- Suicide / Self-Harm Risk: Low.
- Ideation: Patient explicitly denies active suicidal ideation, homicidal ideation, plans, or intent.
- Protective Factors: Strong paternal devotion to children (Ian and Lucille), future orientation
toward career, active therapeutic alliance.

[CONTEXT HANDLING INSTRUCTIONS]
1. Current Transcript = evidence for the current encounter.
2. Historical Patient Context = background/history only.
3. Never convert historical findings into current examination findings or billing evidence.
4. Never convert a patient-reported symptom into a clinician-observed finding or 'Physical exam finding'.
5. Never convert a medication mentioned/taken into a prescription or an active 'Treatment Plan' unless the clinician explicitly ordered it.
6. Never create a referral unless explicitly ordered.
7. Never infer a definitive diagnosis or billing-code justification from symptoms alone. State 'Possibly related to...' or similar if no diagnosis is confirmed.
8. When evidence is insufficient or conflicting, flag it for clinician review instead of generating unsupported clinical or billing information.
9. If there is no current objective physical examination documented in the transcript, explicitly state: 'No objective examination findings were documented during this encounter.' or 'N/A'.
10. Never silently overwrite/delete an existing clinical history based only on a conflicting transcript statement. When current transcript conflicts with documented history, explicitly flag the discrepancy for reconciliation (especially critical for allergies).
11. Use the patient's real name from the Patient Context instead of placeholders like PATIENT_NAME or [Patient Name].

[CURRENT ENCOUNTER TRANSCRIPT]
Doctor: I am the psychiatrist here in this department.
Patient: I came to see you because my GP sent me to see you, didn't he?
Doctor: Yeah, yeah. He said, come and see a trick cyclist, because then you'll be all right.
Patient: Come and see a trick cyclist? A psychiatrist? Yeah, he not had time to listen to me, you see.
Doctor: OK, he's a GP. He's a doctor.
Patient: But I don't think he's very clever. He's not very clever because he's not OK. Getting to this, you see, he won't let me talk about this. He sort of listens to it sometimes. But then sometimes he doesn't.
Doctor: Right. Can I just clarify why you are here and why I'm here? I'm the psychiatrist.
Patient: Well, I've come to see you in the emergency clinic today.
Doctor: OK. And your GP has asked me to see you? So that's why I'm here. Is that right?
Patient: Yeah, because I got to tell you about this. There's important stuff in there, really important stuff.
Doctor: OK, well, before we start with that, I come to see you. Can I just ask you what you would like me to call you? What name?
Patient: Yeah, name. Name is a game. I don't bother with names. That's just too good.
Doctor: Right, OK. Call me Audrey.
Patient: OK, I'm the psychiatrist over here.
Doctor: OK, now what is Audrey? Can I ask you how old you are, Audrey?
Patient: How old? Oh, don't. You're only as old as the woman you feel, aren't you? I feel quite young and better than most women in their 20s.
Doctor: Right, OK. So how old would that make you, Audrey?
Patient: ID would say I am 35, but I feel 23 and free. Free food, food for the soul, a nice bit of soul.
Doctor: Yeah, right. A bit of fish, fantastic. I'm not half hungry.
Patient: Right, you have any food? Any food here? You have any food? I'm starving.
Doctor: No, they won't be able to get you any food. Let's, OK, now let's get back to this. This is important.
Patient: Yes, that's a good idea. Yep, OK. This is why I'm here to talk to you about this.