🩺 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. These episodes typically occur before major presentations at work. During the panic attacks, the patient experiences intense pounding in the chest, difficulty breathing, cold and clammy hands, dizziness, and a sense of detachment, as if watching themselves from outside their body. The patient is also overwhelmed by catastrophic thoughts, such as the fear of collapsing.
Objective
The patient was referred by their GP to Kynarc for psychological evaluation and treatment. There is no mention of suicidal intent or self-harm.
Assessment
The patient is experiencing panic attacks and insomnia, likely related to work-related stress and anxiety. The symptoms include physical manifestations such as chest tightness, difficulty breathing, and cold hands, as well as psychological symptoms like catastrophic thinking and detachment.
Plan
The plan involves continuing psychological evaluation and treatment to address the panic attacks and insomnia. The patient should be monitored for any changes in symptoms or the emergence of suicidal thoughts, despite current reports of no suicidal intent or self-harm.
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