🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2026-10-02 16:59:58

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]
Doctor: Here, let me get these slippers off. You did a great job on that walk. You sure did, Ms. Adams. How are you feeling?
Patient: Well, I'm kind of glad it's over. It will get easier, won't it?
Doctor: Oh, it will not. It will. That's what we're working towards. So if you both look at the board here, it's spelled out.
Doctor: Mr. Adams, I'm really glad that you're able to be here when we're walking with your wife because I think it's going to give you a better sense of what to expect once you're home and how her recovery is progressing.
Family Member: It certainly will.
Doctor: Now, we gave her the pain medication an hour before she walked so that she would feel comfortable. Then, as you saw, when we got her out of bed, we had her sit on the edge of the bed to make sure she wasn't dizzy from the medications. Then we had her stand for a minute to make sure she was okay before she started walking. That's going to be important to continue once you're at home.
Family Member: Uh-huh. Uh-huh.

Clinical Notes

Clinical Note

Subjective

Ms. Adams expressed relief that the walking session is over and inquired if it would get easier over time. The doctor reassured her that it would improve with continued effort.

Objective

  • The patient was able to walk with assistance.
  • Pain medication was administered an hour prior to walking to ensure comfort.
  • The patient was monitored for dizziness after sitting on the edge of the bed and standing before walking.

Assessment

  • Post-operative recovery is progressing.
  • Pain management appears effective during physical activity.

Plan

  • Continue administering pain medication prior to physical activity.
  • Monitor for dizziness when transitioning from sitting to standing and walking.
  • Educate family on assisting with mobility and recognizing signs of dizziness at home.

[[META_DIRECTIONS_START]] [] [[META_DIRECTIONS_END]]

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