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.]

[PATIENT CLINICAL SUMMARY]
Condition: - Pain in the lower right tooth for 4 days
- Pain worsens with cold drinks or sweets, rated 6/10
- Pain increases to 8/10 when biting down
- Mild swelling near the gum, no bleeding
Medications: Ibuprofen (patient reported) 200 mg tablet (as needed), Ibuprofen
Allergies: Penicillin (causes rash), Amoxicillin (causes hives)
Past Medical History: • Patient presented for routine dental evaluation and follow-up of existing dental restoration, • Reported occasional mild sensitivity in lower right posterior region, especially with harder foods, • Denied facial swelling, gum bleeding, or persistent oral pain, • Fair general oral hygiene with mild plaque accumulation along gingival margins, • History of dental restoration in lower right posterior tooth, • Mild intermittent sensitivity in previously treated area, • Plaque accumulation with mild gingival irritation noted, • Routine oral hygiene, flossing, and monitoring of restored tooth recommended

Recent Past Visits:
  [Sep 26, 2026] Follow-up Visit
  Key Findings: - Pain in the lower right tooth for 4 days - Pain worsens with cold drinks or sweets, rated 6/10 - Pain increases to 8/10 when biting down - Mild swelling near the gum, no bleeding
  Assessment: - Pain in the lower right tooth, possibly related to previous dental restoration - Mild swelling near the gum - Pain exacerbated by cold stimuli and biting - Underlying cause not definitively established

[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. 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: इसके बाद यहाँ पे आके एक PDF सेलेट की है जिसके अंदर context है PDF या docs कोई भी ठीक है मैं देख रहा हूँ तो यहाँ पे अभी एक्स्ट्रक्ट हो जाएगा और यहाँ पे आजाएगा यहाँ यहाँ AI के पास जाएगा इसके बाद save करना होगा इसको और यहाँ पे स्टार्ट करना होगा बोलना तो यह transcript जाएगा हो जाएगा