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 CLINICAL SUMMARY]
Condition: - No specific key findings documented
Medications: Melatonin
Past Medical History: Asthma in childhood, Asthma in young childhood, Asthma
Family History: Maternal genetic vulnerability to anxiety; social anxiety in parent, Maternal genetic vulnerability to anxiety, Anxiety, Depression

Recent Past Visits:
  [Oct 05, 2026] Follow-up Visit
  Key Findings: - No specific key findings documented
  Assessment: - Assessment details not provided
  [Oct 05, 2026] Follow-up Visit
  Key Findings: - Severe anxiety related to school attendance - Symptoms include insomnia, morning panic episodes, nausea, and dizziness - Cognitive distortions exacerbate anxiety
  Assessment: - Severe separation anxiety and school avoidance - Likely related to academic demands and cognitive distortions - Family history of anxiety and naturally sensitive temperament
  [Oct 05, 2026] Follow-up Visit
  Key Findings: - No specific key findings documented
  Assessment: - Assessment details not provided

[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]
New patient visit, follow-up for chronic low back pain. Patient is Sarah Mitchell, date of birth March 14, 1979, insurance is Blue Cross Blue Shield PPO, member ID BCB4471982, group number 55210.

Chief complaint: lower back pain radiating down the left leg, six weeks duration, not improving with conservative treatment.

History: patient reports pain began after lifting a heavy box, rates it 7 out of 10, worse with sitting and bending forward. Has completed four weeks of physical therapy and a trial of ibuprofen 600 milligrams three times daily with minimal relief. No red flag symptoms -- no bowel or bladder changes, no saddle anesthesia, no fever.

Exam: positive straight leg raise on the left at 40 degrees, decreased sensation in the left L5 dermatome, 4 out of 5 strength in left great toe extension. Reflexes symmetric. Gait is antalgic but independent.

Assessment: lumbar radiculopathy, likely L5 nerve root, secondary to suspected disc herniation. Diagnosis code M54.16, lumbar radiculopathy.

Plan: given six weeks of failed conservative therapy with a progressive neurologic finding, ordering MRI of the lumbar spine without contrast, CPT 72148, to evaluate for disc herniation and nerve root compression. Given findings this will likely require prior authorization from Blue Cross Blue Shield before scheduling. Also refilling ibuprofen 600 milligrams, continuing physical therapy twice weekly for four more weeks, and referring to orthopedic spine if imaging confirms significant pathology. Follow-up in two weeks or sooner if symptoms worsen.