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]
CLINICAL ASSESSMENT RECORD (General Medical Visit)
Client Name: Not stated | DOB / Age:12-09-2000 (Male)
Client ID: Not stated | Visit Date: Not stated
Assessing Clinician: Not stated (physician)
Care Pathway: Acute Illness / Same-Day Visit
Accompanied by: Concerned companion (relationship not stated)
1. PRIMARY CLINICAL PRESENTATION
Acute influenza-type illness. Persistent fever that "won't break," difficulty sleeping, painful
breathing, and ongoing cough. The companion reports shortness of breath. The patient
downplayed symptoms ("it's nothing") and is worried about returning to work on Monday.
2. BIOPSYCHOSOCIAL FORMULATION (4P)
● Predisposing: Not stated.
● Precipitating: Acute viral illness, diagnosed as influenza rather than a cold.
● Perpetuating: Insomnia, minimizing symptoms, pressure to return to work (Monday),
and likely continued work activity (laptop).
● Protective: Engaged companion who brought her in and will enforce rest; she sought
care and the doctor gave a clear plan.
3. BASELINE CLINICAL MEASURES
● Temperature: ~38.4 °C (fever). Verify against audio.
● Chest/breathing check: deep-breath examination performed. No findings stated.
● Throat examination performed. No findings stated.
4. SAFETY & RISK SCREEN
Respiratory distress was reported by the companion ("can't breathe"). No formal risk screen is
stated. A return-to-clinic safety net was given: come straight back if the fever does not break
within the stated timeframe.
5. TREATMENT PLAN & RECOMMENDED INTERVENTIONS
● Rest, including no return to work Monday.
● Prescription for fever and for sleep (medication name not recovered from the audio).
● Companion to enforce rest ("even if I have to hide her laptop").
● Follow-up: return immediately if the fever has not broken by the stated time (timeframe
not recovered).

[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: Can I add the context now?
Patient: Yeah.
Doctor: Okay, actually. Um, nevermind. Just do it. Just do it. Can I put the audio now?
Patient: Yeah.
Doctor: Play the audio. Don't upload it. Play it. Okay. Sit down. You look exhausted. Tell me what's going on.
Patient: Doctor, I can't sleep. The fever won't break. Look, every breath hurts.
Family Member: She's been coughing until she can't breathe. She kept saying it was nothing. Look at her. It is not nothing.
Doctor: All right. Deep breath for me again. Temperature is 38.5. Throat's inflamed. This is influenza, not a cold.
Patient: Is it serious? I have to be back at work on Monday.
Doctor: You'll be fine, but your body needs rest, real rest. I'll prescribe something for the fever, water, sleep, no heroics.
Family Member: Don't worry, doctor. I'll keep her in bed, even if I have to hide her laptop.
Doctor: Perfect. And Sarah, if that fever hasn't broken by Thursday, you come straight back to me.