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]
Dental Visit SOAP Note
Patient: Mr. John Doe
Date of Birth: 30-10-2001
Gender: Male
Phone: (416) 555-0123
Address: 123 Queen Street West, Toronto, ON M5H 2M9
Visit Date: 15-09-2026
Reason for Visit: Follow-up of sensitivity in the lower right back tooth
Insurance Information
• Insurance Provider: Sun Life Financial
• Plan Name: Group Dental Plan
• Member ID: SLF-4482917
• Group Number: 7765-01
• Policy Holder: John Doe (Self)
• Coverage Effective Date: 01-01-2026
S — Subjective
• Chief complaint: mild, intermittent sensitivity in the lower right posterior tooth (tooth 46)
when chewing harder foods and with cold drinks, present for about 3 weeks.
• No spontaneous toothache. Patient denies facial swelling, gum bleeding, fever or persistent
oral pain.
• Brushes twice daily and flosses intermittently.
• Current Medications:
◦ Ibuprofen 200 mg tablet — 1 tablet by mouth every 6 to 8 hours as needed for dental
discomfort.
◦ Vitamin D3 1000 IU — 1 tablet by mouth once daily.
• Allergies:
◦ Penicillin — causes rash.
◦ Amoxicillin — causes hives.
• Past Medical History:
◦ Composite restoration of the lower right first molar (tooth 46) in 2023.
◦ Extraction of impacted lower wisdom teeth in 2019.
◦ Tonsillectomy in 2010.
• Family History:
◦ Father — hypertension.
◦ Mother — type 2 diabetes mellitus.
• Social History:
◦ Non-smoker; denies tobacco use.
◦ Drinks alcohol occasionally (socially).
◦ Works as a software developer.
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O — Objective
• Vital Signs (measured 15-09-2026): Blood pressure 122/78 mmHg; Heart rate 74 bpm;
Temperature 36.9 °C; Respiratory rate 16 breaths/min; Oxygen saturation (SpO2) 98%.
• Weight: 78 kg. Height: 178 cm.
• Existing composite restoration on tooth 46 is intact with slight marginal wear.
• Mild plaque accumulation along the gingival margins with mild gingival inflammation in the
lower anterior region.
• Cold test on tooth 46: brief sensitivity that resolves within seconds (reversible).
• Bitewing radiograph: no recurrent caries and no periapical abnormality.
• Recent Laboratory Results (from family physician, 02-09-2026):
◦ Hemoglobin A1C: 5.4 % (reference range 4.0 – 5.6) — normal.
◦ Fasting blood glucose: 92 mg/dL (reference range 70 – 99) — normal.
A — Assessment
• Dentin hypersensitivity of the lower right first molar (tooth 46) — ICD-10 K03.89.
• Plaque-induced chronic gingivitis — ICD-10 K05.10.
• Existing restoration on tooth 46 intact; no signs of pulpitis, abscess or infection.
P — Plan
• Prescribed today:
◦ Sodium fluoride 1.1% (5000 ppm) toothpaste — apply once daily at bedtime; spit, do not
rinse.
◦ Chlorhexidine gluconate 0.12% oral rinse — rinse with 15 mL twice daily for 14 days.
• Continue ibuprofen only as needed for occasional dental discomfort.
• Brush twice daily with a soft toothbrush and floss daily.
• Recall visit and cleaning in 6 months; return earlier if pain persists or swelling or fever
develops.
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[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]
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?
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 here?
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.