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 Context
Vist Date:25-09-2026
Patient Name: Audrey
Gender: Female
Age: 32 (DOB: 1994-04-18)
MRN: KIN-2026-AUD89
Attending Clinician: Dr. Liam Mitchell, Ph.D., C.Psych.
Clinic: Kinark Child, Youth and Family Mental Health Services
Encounter Type: Outpatient Clinical Intake & CBT Diagnostic Consultation
Referral Source: Family Physician / GP (referred for acute panic attacks and sleep disruption)
[CHIEF COMPLAINT & PRESENTING HISTORY]
Audrey is a 32-year-old female presenting with a 3-month history of sudden, escalating panic
attacks and anticipatory anxiety primarily triggered by high-stakes work presentations and
late-afternoon professional demands.
Somatic Symptoms:
- Acute tachycardia (violent heart pounding)
- Chest constriction and subjective shortness of breath (dyspnea)
- Diaphoresis (cold, clammy palms)
- Lightheadedness, dizziness, and episodic derealization ("feeling detached, watching myself
from outside my body")
Cognitive Distortions:
- Catastrophizing and fear of loss of control: "What if I collapse right here? What if I lose control
and everyone notices?"
Behavioral Manifestations:
- Maladaptive escape behaviors (leaving meetings abruptly, retreating to car, heading home)
- Negative reinforcement cycle: immediate panic reduction upon leaving followed by amplified
anticipatory dread the following day
- Developing agoraphobic avoidance: avoiding in-person client presentations and social dinners
Sleep & Physical Health:
- Sleep-onset insomnia with racing thoughts lasting until 2:00–3:00 AM; morning nausea
- No chronic medical conditions; recent GP routine blood work and thyroid panel normal
[MENTAL STATUS EXAMINATION (MSE)]
- Appearance: Well-groomed 32-year-old female, dressed appropriately, mild motor tension in
hands.
- Behavior: Cooperative, fully engaged, maintains natural eye contact, no psychomotor
agitation.
- Speech: Clear, fluent, normal rate, volume, and latency.

- Mood & Affect: Anxious and apprehensive initially; congruent, responsive, relieved by
psychoeducation.
- Thought Process: Linear, goal-directed, coherent, logical. No flight of ideas or thought disorder.
- Thought Content: Preoccupied with visceral sensations of panic and fear of public
incapacitation. No hallucinations, delusions, or paranoia.
- Safety & Risk: Low acute risk. Explicitly denies suicidal ideation, intent, plan, or self-harm
history.
- Insight & Judgment: Intact, strong psychological mindedness, motivated for
cognitive-behavioral therapy.
[DIAGNOSTIC IMPRESSION]
- Primary: Panic Disorder with Agoraphobic Avoidance (ICD-10 F41.0 / DSM-5 300.01)
- Secondary: Adjustment-Related Sleep-Onset Insomnia (ICD-10 G47.00)
[PLAN & INTERVENTIONS]
1. Psychoeducation on autonomic sympathetic nervous system fight-or-flight response and
negative reinforcement of avoidance.
2. Introduction of 4-4-6 Paced Diaphragmatic Breathing (4s inhale through nose, 4s hold, 6s
exhale pursed lips) for vagal nerve stimulation.
3. Daily Kinark Three-Column CBT Thought Record to track panic triggers and challenge
catastrophic automatic thoughts.
4. Next follow-up individual 50-minute CBT session confirmed with Dr. Mitchell for next Tuesday
at 3:00 PM.

[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 afternoon, Dr. Mitchell. Honestly, I've had a lot of nervous tension. My GP referred me to Kynarc after I started having sudden panic attacks and severe insomnia over the last three months.
Doctor: Thank you for sharing that openly, Audrey. It takes real courage to take that first step. Can you walk me through what happens during these panic episodes?
Patient: It usually happens before major presentations at work. My heart begins pounding intensely, my chest tightens up so I feel like I can't catch my breath, and my hands get cold and slimy. I feel dizzy and detached, like I'm watching myself from outside my body.
Doctor: What thoughts tend to race through your mind during those physical surges?
Patient: I get flooded with catastrophic thoughts. What if I collapse right here? What if I lose control and everyone notices? It feels so overwhelming that I make an excuse and retreat to my car or head home early.
Doctor: That's a textbook panic cycle. Escaping provides immediate relief through a negative reinforcement, but it trains the brain that the situation was dangerous, reinforcing the fear over time. Let's check physical health and safety. Any chronic conditions? And have you ever had thoughts of suicide or self-harm?
Patient: No chronic conditions. My GP ran full blood work last month and everything was completely normal. And absolutely no thoughts of self-harm or suicide, Dr. Mitchell. I love my life, I just really want my confidence and peace of mind back.
Doctor: Thank you, Audrey. Clinical assessment confirms low risk with zero suicidal intent or self-harm history. For our plan at KENARCH, we will use cognitive behavioral therapy. Today, we'll practice 4-4-6-paced breathing to regulate your autonomic nervous system and track triggers with a CPT thought record. Let's schedule our next individual session for next Tuesday at 3 p.m.
Patient: That sounds very grounded and practical. Having a physiological tool gives me real hope. Tuesday at 3 p.m. works wonderfully. Thank you so much, Dr. Mitchell.
Doctor: You're very welcome, Audrey. Have a safe afternoon, and we'll see you next Tuesday.