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 CLINICAL SUMMARY]
Condition: - Symptoms of stable angina: central chest pressure after exertion, radiating to left shoulder, resolving with rest
- Uncontrolled diabetes with rising A1c
- Blurry vision and loose stools reported on metformin
- Hypertension above goal
Medications: Ibuprofen (patient reported) 200 mg tablet (as needed), Ibuprofen, Metformin 1000 mg BID, Lisinopril 20 mg daily, Atorvastatin 40 mg daily, Omeprazole 20 mg daily
Allergies: Sulfa (rash), Hyperlipidemia (Gallstone pancreatitis, March 2021, reso), GERD (BMI 33), Family history (father had MI at 58)
Past Medical History: Type 2 diabetes (dx 2017), Hypertension (dx 2015), Hyperlipidemia, Gallstone pancreatitis, resolved; cholecystectomy April 2021, GERD, BMI 33.8
Family History: Father had MI at 58
Prescriptions: Nitroglycerin 0.4 mg sublingual tablets, dispense 25, Semaglutide 0.25 mg subcutaneously once weekly for four weeks, then 0.5 mg weekly with starter pen for the first month, Amlodipine 5 mg once daily

Recent Past Visits:
  [Sep 26, 2026] Follow-up Visit
  Key Findings: - Symptoms of stable angina: central chest pressure after exertion, radiating to left shoulder, resolving with rest - Uncontrolled diabetes with rising A1c - Blurry vision and loose stools reported on metformin - Hypertension above goal
  Assessment: - Likely stable angina with chest pain after exertion - Uncontrolled type 2 diabetes with rising A1c - Hypertension above goal - Possible diabetic retinopathy (underlying cause not definitively established)
  [Sep 26, 2026] Follow-up Visit
  Key Findings: - Pain in the lower right tooth for 4 days - Pain worsens with cold drinks or sweets, rated 6/10 - Pain increases to 8/10 when biting down - Mild swelling near the gum, no bleeding
  Assessment: - Pain in the lower right tooth, possibly related to previous dental restoration - Mild swelling near the gum - Pain exacerbated by cold stimuli and biting - Underlying cause not definitively established

[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]
NIO DEMO - SOLO DICTATION SCRIPT
Patient: Daniel Reyes (synthetic test patient)

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SECTION 1: DICTATION (read aloud)
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"Okay, dictating the visit for Daniel Reyes.

Quick aside before I start, I need to call the pharmacy rep back about the samples, not part of this note.

Daniel came in today for follow-up on his diabetes and to review his recent bloodwork, but the main new issue is chest discomfort. He describes about three to four weeks of central chest pressure that comes on after roughly five minutes of walking uphill or carrying groceries. It sometimes radiates to the left shoulder. It resolves within a couple of minutes of rest. He gets mildly short of breath with it but no sweating, no nausea. It has never happened at rest or woken him from sleep, and the frequency and effort needed to bring it on haven't changed.

Review of systems: he reports some blurry vision with reading. No numbness or tingling in the feet. He's still having loose stools on metformin and admits he's been skipping the evening dose.

Exam: blood pressure 148 over 92, heart rate 78, weight 104 kilos. Heart regular, no murmurs. Lungs clear. No peripheral edema. Diabetic foot exam: pedal pulses intact, monofilament sensation intact bilaterally, no ulcers.

Plan.

One. Chest pain, likely stable angina. Twelve-lead ECG done in office today. Referral to cardiology for stress testing. Start nitroglycerin 0.4 milligram sublingual spray, one spray as needed for chest pain, may repeat every five minutes up to three doses. Counseled him to call 911 for chest pain at rest, pain lasting over fifteen minutes, or pain with sweating or lightheadedness.

Two. Type 2 diabetes, uncontrolled. Start semaglutide 0.25 milligrams subcutaneously once weekly for four weeks, then 0.5 milligrams weekly. Needs prior authorization. Switch metformin from immediate release 1000 twice daily to extended release 2000 milligrams once daily with dinner.

Three. Hypertension, above goal. Increase lisinopril from 20 to 40 milligrams daily. Basic metabolic panel in two weeks.

Four. Blurry vision, diabetic eye exam due. Referral to ophthalmology for a dilated retinal exam.

Five. Influenza vaccine given today.

Follow-up in six weeks. Repeat A1c in three months.

Okay, now some changes before you finalize.

For the note structure: don't use SOAP for this one, write it as a problem-oriented note, with each problem getting its own assessment and plan. Put the chest pain first since it's the most important issue. Move the metformin side effects and missed doses out of review of systems and under the diabetes problem. Keep the foot exam as its own line labeled diabetic foot exam. And add a short one-line summary at the very top of the note.

For prescriptions: change the lisinopril. Instead of going up to 40, keep lisinopril at 20 and add amlodipine 5 milligrams once daily. Keep the two-week bloodwork anyway. For the nitroglycerin, switch from the spray to sublingual tablets, 0.4 milligrams, dispense 25. For semaglutide, make sure the prescription covers the titration, so a starter pen for the first month, then the 0.5 dose. And remove the metformin immediate release from the med list entirely, don't just mark it as changed.

Last thing, in the patient summary, put the 911 warning signs at the very top in plain language.

End of dictation."


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SECTION 2: PRELOAD CONTEXT (load into Nio before dictating - do NOT read aloud)
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Patient: Daniel Reyes, 56M, DOB 1970-03-14
Insurance: Aetna Choice POS II, Member ID W284719365, Group 0918472
Allergies: Sulfa (rash)

Problem list:
- Type 2 diabetes (dx 2017)
- Hypertension (dx 2015)
- Hyperlipidemia
- Gallstone pancreatitis, March 2021, resolved; cholecystectomy April 2021
- GERD
- BMI 33.8

Current medications:
- Metformin 1000 mg BID
- Lisinopril 20 mg daily
- Atorvastatin 40 mg daily
- Omeprazole 20 mg daily

Lab trend:
Date        A1c   eGFR   UACR (mg/g)   K+    LDL
Sep 2025    7.6   78     22            4.4   88
Mar 2026    8.3   71     41            4.7   92
Aug 2026    8.9   66     58            5.1   95

Prior visit notes (summary):
- Mar 2026: A1c rising. Discussed adding second agent; patient declined, wanted to try diet first. Diabetic eye exam overdue (last done 2023).
- Jun 2026 (phone): Patient reported loose stools on metformin, advised taking with meals.
- Family history: father had MI at 58.