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]
[PATIENT DEMOGRAPHICS]
Patient Name: Audrey
Gender: Female
Age: 35 (DOB: 1991-03-14)
Encounter Type: Urgent / Emergency Psychiatric Clinic Assessment
Provider: Emergency Consultant Psychiatrist
Referral Source: General Practitioner (GP)

[CHIEF COMPLAINT & PRESENTING HISTORY]
Audrey is a 35-year-old female presenting to the emergency psychiatric clinic on urgent referral from her GP (whom she colloquially refers to as having sent her to a "trick cyclist"). Patient reports frustration with her GP, stating he was "not very clever" and did not give her time to talk about urgent, undisclosed information/materials she brought to the clinic ("There's important stuff in there. Really important stuff"). 

[MENTAL STATUS EXAMINATION (MSE) FINDINGS IN SESSION]
- Appearance & Behavior: Alert, animated, highly preoccupied with materials in her possession. Preoccupied with immediate physical cravings (acute hunger, repeatedly asking clinic staff for food).
- Speech & Thought Process: Pressured speech, flight of ideas, loose associations, and clang/rhyming associations ("name is a game", "23 and free -> free food -> food for the soul -> bit of sole/fish"). Easily distracted.
- Mood & Affect: Expansive, elevated, euphoric with underlying irritability ("You're only as old as the woman you feel... I feel quite young and better than most women in their 20s").
- Cognition & Orientation: States her ID confirms she is 35 years old, but reports feeling "23 and free".
- Thought Content: Fixated on urgent undisclosed concerns that her GP allegedly refused to listen to; signs of racing thoughts and hypomanic/manic state.

[CLINICAL ASSESSMENT & DIAGNOSTIC IMPRESSION]
- Differential Diagnosis:
  1. Bipolar I Disorder, Current Episode Manic / Hypomanic with flight of ideas (ICD-10 F31.1).
  2. Cyclothymia / Bipolar Spectrum Disorder.
  3. Acute psychiatric crisis / Psychosis NOS under investigation.

[SESSION PLAN]
- Clarify presenting crisis and examine the contents/concerns patient brought in.
- Complete psychiatric risk assessment, collateral medical history, and somatic/nutritional check.
- Provide oral fluids and nutritional support in clinic.
- Evaluate need for mood stabilizer initiation, atypical antipsychotic medication, or inpatient crisis stabilization.

[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]
Doctor: I am the psychiatrist here in this department.
Patient: I came to see you because my GP sent me to see you, didn't he?
Doctor: Yeah, yeah.
Patient: He said come and see a trick cyclist because then you'll be alright.
Doctor: Come and see a trick cyclist? A psychiatrist?
Patient: Yeah. He not had time to listen to me, you see.
Doctor: Okay, he's a GP. He's a doctor.
Patient: But I don't think he's very clever. He's not very clever because he's not okay. Getting to this, you see, he won't let me talk about this. He sort of listens to it sometimes, but then sometimes he doesn't.
Doctor: Right. Can I just clarify why you are here and why I'm here? I'm the psychiatrist.
Patient: Well, I've come to see you in the emergency clinic today.
Doctor: Okay. And your GP has asked me to see you? So that's why I'm here. Is that right?
Patient: Yeah, because I got to tell you about this. There's important stuff in there. Really important stuff.
Doctor: Okay. Well, before we start with that, I come to see you. Can I just ask you what you would like me to call you? What name?
Patient: Yeah. Name. Name is a game. I don't bother with names. That's just too good.
Doctor: Right. Okay. Call me Audrey.
Patient: Okay. I'm the psychiatrist over here.
Doctor: Okay. Now, what is Audrey? Can I ask you how old you are, Audrey?
Patient: How old? Oh, don't. You're only as old as the woman you feel, aren't you? I feel quite young and better than most women in their 20s.
Doctor: Right. Okay. So how old would that make you, Audrey?
Patient: My ID would say I am 35, but I feel 23 and free. Free food. Food for the soul. A nice bit of soul.
Doctor: Yeah, I.
Patient: Right. A bit of fish. Ah, fantastic. I'm not half hungry.
Doctor: Right. You have any food? Any food here? You have any food? I'm starving.
Patient: Nah. They won't be able to get you any food. Let's.
Doctor: Okay. Now let's get back to this. This is important.
Patient: Yes. That's a good idea.
Doctor: Yep. Okay. This is why I'm here to talk to you about this.