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]
Past Visit SOAP Note
Patient: Mr. John Doe
Visit Date: Previous Dental Visit
S — Subjective
• Patient previously presented for routine dental evaluation and follow-up of an existing dental
restoration.
• Patient reported occasional mild sensitivity in the lower right posterior region, particularly with
chewing harder foods.
• No significant spontaneous toothache was reported at that visit.
• Patient denied facial swelling, gum bleeding, or persistent oral pain.
• Patient reported brushing twice daily and using dental floss intermittently.
• Current Medications:
• Ibuprofen 200 mg tablet — taken occasionally as needed for dental discomfort.
• No other regular medications reported.
• Allergies:
• Penicillin — causes rash.
• Amoxicillin — causes hives.
O — Objective
• General oral hygiene was fair.
• Previous dental restoration noted in the lower right posterior region.
• Mild plaque accumulation noted along the gingival margins.
• No obvious gingival bleeding or significant soft-tissue swelling observed at the previous visit.
• No acute dental abscess or facial swelling documented.
• Previous dental radiograph showed no acute periapical abnormality.
A — Assessment
• History of dental restoration involving the lower right posterior tooth.
• Mild intermittent sensitivity associated with the previously treated area.
• Plaque accumulation with mild gingival irritation.
• No acute infection or significant periodontal findings documented during the previous visit.
P — Plan
• Continue routine oral hygiene and twice-daily brushing.
• Encourage regular flossing/interdental cleaning.
• Continue ibuprofen only as needed for occasional dental discomfort, as previously directed.
• Monitor the previously restored lower right tooth for changes in sensitivity or pain.
• Routine dental follow-up recommended.
• Return earlier if persistent pain, swelling, fever, or other acute dental symptoms develop.
• Documented Allergies: Penicillin — rash; Amoxicillin — hives.
1

[CONTEXT HANDLING INSTRUCTIONS]
1. Patient Context = historical/persisted information.
2. Transcript = current encounter information.
3. Generate the current visit assessment primarily from the current transcript.
4. Use historical context only when relevant; do not incorrectly present historical findings as current findings.
5. Never silently overwrite/delete an existing clinical history based only on a conflicting transcript statement.
6. When current transcript conflicts with documented history, preserve the existing historical record and explicitly flag the discrepancy for reconciliation (especially critical for allergies, medications, and diagnoses).
7. Do not infer diagnoses, prescriptions, allergies, medication changes, or causation unless supported by the provided information.
8. Historical facts such as previous restorations may be referenced as relevant history, but must not be presented as newly observed current findings unless confirmed by the current transcript.
9. Current-visit data must not be incorrectly inserted into pastVisits as if it were an older encounter.
10. Never convert a symptom, historical condition, patient-reported medication use, or historical finding into a confirmed diagnosis, prescription, referral, current objective finding, or billing code unless it is explicitly supported by the current encounter documentation.
11. Never place patient-reported symptoms in Objective unless a clinician explicitly documents them as observed or measured.
12. Never create a prescription from medication merely mentioned or taken by the patient. Separate 'Medication reported/used' from 'Medication prescribed'.
13. Never infer a definitive diagnosis or billing code from symptoms alone. Billing evidence must quote or accurately summarize ONLY documentation present in the current encounter.
14. If there is no current objective physical examination documented in the transcript, explicitly state: 'No current objective examination findings were documented' instead of inventing them or importing them from history.
Doctor: Brings you in today.
Patient: Good morning, doctor. I've been having pain in my lower right tooth for about four days. It gets worse when I drink something cold or eat sweets.
Doctor: Have you noticed any swelling or bleeding around the tooth?
Patient: There is a little swelling near the gum, but I haven't noticed any bleeding.
Doctor: Okay. On a scale of one to ten, how would you rate the pain?
Patient: Around a six. It becomes an eight when I bite down.
Doctor: Does the pain stay in the tooth or does it spread toward your jaw or ear?
Patient: Sometimes it spreads toward my right jaw, especially at night.
Doctor: Have you taken anything for the pain?
Patient: I took ibuprofen yesterday evening and it helped for a few hours.
Doctor: Do you have any known medication allergies?
Patient: No, I don't have any known allergies.
Doctor: Good morning.