diff --git "a/training_data.json" "b/training_data.json" new file mode 100644--- /dev/null +++ "b/training_data.json" @@ -0,0 +1,70002 @@ +[ + { + "id": "note_0000", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0001", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0002", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0003", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0004", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0005", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0006", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0007", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0008", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0009", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0010", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0011", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0012", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0013", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0014", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0015", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0016", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0017", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0018", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0019", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0020", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0021", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0022", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0023", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0024", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0025", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0026", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0027", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0028", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0029", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0030", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0031", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0032", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0033", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0034", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0035", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0036", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0037", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0038", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0039", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0040", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0041", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0042", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0043", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0044", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0045", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0046", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0047", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0048", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0049", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0050", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0051", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0052", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0053", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0054", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0055", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0056", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0057", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0058", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0059", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0060", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0061", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0062", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0063", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0064", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0065", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0066", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0067", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0068", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0069", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0070", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0071", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0072", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0073", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0074", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0075", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0076", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0077", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0078", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0079", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0080", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0081", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0082", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0083", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0084", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0085", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0086", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0087", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0088", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0089", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0090", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0091", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0092", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0093", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0094", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0095", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0096", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0097", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0098", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0099", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0100", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0101", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0102", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0103", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0104", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0105", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0106", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0107", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0108", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0109", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0110", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0111", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0112", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0113", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0114", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0115", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0116", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0117", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0118", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0119", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0120", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0121", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0122", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0123", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0124", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0125", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0126", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0127", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0128", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0129", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0130", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0131", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0132", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0133", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0134", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0135", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0136", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0137", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0138", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0139", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0140", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0141", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0142", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0143", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0144", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0145", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0146", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0147", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0148", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0149", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0150", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0151", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0152", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0153", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0154", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0155", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0156", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0157", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0158", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0159", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0160", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0161", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0162", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0163", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0164", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0165", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0166", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0167", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0168", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0169", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0170", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0171", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0172", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0173", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0174", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0175", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0176", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0177", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0178", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0179", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0180", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0181", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0182", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0183", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0184", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0185", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0186", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0187", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0188", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0189", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0190", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0191", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0192", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0193", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0194", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0195", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0196", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0197", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0198", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0199", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0200", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0201", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0202", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0203", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0204", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0205", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0206", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0207", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0208", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0209", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0210", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0211", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0212", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0213", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0214", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0215", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0216", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0217", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0218", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0219", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0220", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0221", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0222", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0223", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0224", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0225", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0226", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0227", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0228", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0229", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0230", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0231", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0232", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0233", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0234", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0235", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0236", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0237", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0238", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0239", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0240", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0241", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0242", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0243", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0244", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0245", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0246", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0247", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0248", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0249", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0250", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0251", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0252", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0253", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0254", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0255", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0256", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0257", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0258", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0259", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0260", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0261", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0262", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0263", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0264", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0265", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0266", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0267", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0268", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0269", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0270", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0271", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0272", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0273", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0274", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0275", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0276", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0277", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0278", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0279", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0280", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0281", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0282", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0283", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0284", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0285", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0286", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0287", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0288", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0289", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0290", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0291", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0292", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0293", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0294", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0295", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0296", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0297", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0298", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0299", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0300", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0301", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0302", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0303", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0304", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0305", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0306", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0307", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0308", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0309", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0310", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0311", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0312", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0313", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0314", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0315", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0316", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0317", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0318", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0319", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0320", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0321", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0322", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0323", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0324", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0325", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0326", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0327", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0328", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0329", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0330", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0331", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0332", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0333", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0334", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0335", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0336", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0337", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0338", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0339", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0340", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0341", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0342", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0343", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0344", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0345", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0346", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0347", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0348", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0349", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0350", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0351", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0352", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0353", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0354", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0355", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0356", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0357", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0358", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0359", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0360", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0361", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0362", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0363", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0364", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0365", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0366", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0367", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0368", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0369", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0370", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0371", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0372", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0373", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0374", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0375", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0376", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0377", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0378", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0379", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0380", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0381", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0382", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0383", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0384", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0385", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0386", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0387", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0388", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0389", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0390", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0391", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0392", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0393", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0394", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0395", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0396", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0397", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0398", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0399", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0400", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0401", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0402", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0403", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0404", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0405", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0406", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0407", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0408", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0409", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0410", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0411", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0412", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0413", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0414", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0415", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0416", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0417", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0418", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0419", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0420", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0421", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0422", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0423", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0424", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0425", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0426", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0427", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0428", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0429", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0430", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0431", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0432", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0433", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0434", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0435", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0436", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0437", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0438", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0439", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0440", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0441", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0442", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0443", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0444", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0445", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0446", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0447", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0448", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0449", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0450", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0451", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0452", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0453", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0454", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0455", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0456", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0457", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0458", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0459", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0460", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0461", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0462", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0463", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0464", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0465", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0466", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0467", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0468", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0469", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0470", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0471", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0472", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0473", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0474", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0475", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0476", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0477", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0478", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0479", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0480", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0481", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0482", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0483", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0484", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0485", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0486", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0487", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0488", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0489", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0490", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0491", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0492", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0493", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0494", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0495", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0496", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0497", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0498", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0499", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0500", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0501", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0502", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0503", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0504", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0505", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0506", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0507", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0508", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0509", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0510", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0511", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0512", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0513", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0514", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0515", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0516", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0517", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0518", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0519", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0520", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0521", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0522", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0523", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0524", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0525", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0526", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0527", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0528", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0529", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0530", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0531", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0532", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0533", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0534", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0535", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0536", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0537", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0538", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0539", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0540", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0541", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0542", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0543", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0544", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0545", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0546", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0547", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0548", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0549", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0550", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0551", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0552", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0553", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0554", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0555", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0556", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0557", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0558", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0559", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0560", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0561", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0562", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0563", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0564", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0565", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0566", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0567", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0568", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0569", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0570", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0571", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0572", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0573", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0574", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0575", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0576", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0577", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0578", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0579", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0580", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0581", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0582", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0583", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0584", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0585", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0586", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0587", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0588", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0589", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0590", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0591", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0592", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0593", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0594", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0595", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0596", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0597", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0598", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0599", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0600", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0601", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0602", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0603", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0604", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0605", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0606", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0607", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0608", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0609", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0610", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0611", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0612", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0613", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0614", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0615", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0616", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0617", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0618", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0619", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0620", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0621", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0622", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0623", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0624", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0625", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0626", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0627", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0628", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0629", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0630", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0631", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0632", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0633", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0634", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0635", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0636", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0637", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0638", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0639", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0640", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0641", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0642", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0643", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0644", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0645", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0646", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0647", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0648", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0649", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0650", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0651", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0652", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0653", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0654", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0655", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0656", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0657", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0658", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0659", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0660", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0661", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0662", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0663", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0664", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0665", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0666", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0667", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0668", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0669", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0670", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0671", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0672", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0673", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0674", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0675", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0676", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0677", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0678", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0679", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0680", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0681", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0682", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0683", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0684", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0685", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0686", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0687", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0688", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0689", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0690", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0691", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0692", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0693", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0694", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0695", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0696", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0697", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0698", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0699", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0700", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0701", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0702", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0703", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0704", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0705", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0706", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0707", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0708", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0709", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0710", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0711", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0712", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0713", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0714", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0715", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0716", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0717", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0718", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0719", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0720", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0721", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0722", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0723", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0724", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0725", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0726", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0727", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0728", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0729", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0730", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0731", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0732", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0733", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0734", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0735", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0736", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0737", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0738", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0739", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0740", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0741", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0742", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0743", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0744", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0745", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0746", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0747", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0748", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0749", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0750", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0751", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0752", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0753", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0754", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0755", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0756", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0757", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0758", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0759", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0760", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0761", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0762", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0763", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0764", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0765", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0766", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0767", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0768", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0769", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0770", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0771", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0772", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0773", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0774", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0775", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0776", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0777", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0778", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0779", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0780", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0781", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0782", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0783", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0784", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0785", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0786", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0787", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0788", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0789", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0790", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0791", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0792", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0793", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0794", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0795", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0796", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0797", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0798", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0799", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0800", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0801", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0802", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0803", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0804", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0805", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0806", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0807", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0808", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0809", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0810", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0811", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0812", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0813", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0814", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0815", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0816", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0817", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0818", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0819", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0820", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0821", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0822", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0823", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0824", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0825", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0826", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0827", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0828", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0829", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0830", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0831", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0832", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0833", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0834", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0835", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0836", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0837", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0838", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0839", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0840", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0841", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0842", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0843", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0844", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0845", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0846", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0847", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0848", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0849", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0850", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0851", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0852", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0853", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0854", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0855", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0856", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0857", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0858", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0859", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0860", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0861", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0862", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0863", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0864", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0865", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0866", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0867", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0868", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0869", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0870", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0871", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0872", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0873", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0874", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0875", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0876", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0877", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0878", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0879", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0880", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0881", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0882", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0883", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0884", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0885", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0886", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0887", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0888", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0889", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0890", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0891", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0892", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0893", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0894", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0895", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0896", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0897", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0898", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0899", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0900", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0901", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0902", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0903", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0904", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0905", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0906", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0907", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0908", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0909", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0910", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0911", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0912", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0913", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0914", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0915", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0916", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0917", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0918", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0919", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0920", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0921", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0922", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0923", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0924", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0925", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0926", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0927", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0928", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0929", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0930", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0931", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0932", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0933", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0934", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0935", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0936", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0937", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0938", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0939", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0940", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0941", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0942", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0943", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0944", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0945", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0946", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0947", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0948", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0949", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0950", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0951", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0952", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0953", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0954", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0955", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0956", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0957", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0958", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0959", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0960", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0961", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0962", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0963", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0964", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0965", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0966", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0967", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0968", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0969", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0970", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0971", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0972", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0973", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0974", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0975", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0976", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0977", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0978", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0979", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0980", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0981", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0982", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0983", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0984", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0985", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0986", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0987", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0988", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0989", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0990", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0991", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0992", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_0993", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_0994", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_0995", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0996", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_0997", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_0998", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_0999", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1000", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1001", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1002", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1003", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1004", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1005", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1006", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1007", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1008", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1009", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1010", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1011", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1012", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1013", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1014", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1015", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1016", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1017", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1018", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1019", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1020", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1021", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1022", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1023", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1024", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1025", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1026", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1027", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1028", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1029", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1030", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1031", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1032", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1033", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1034", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1035", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1036", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1037", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1038", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1039", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1040", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1041", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1042", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1043", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1044", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1045", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1046", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1047", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1048", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1049", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1050", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1051", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1052", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1053", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1054", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1055", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1056", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1057", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1058", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1059", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1060", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1061", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1062", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1063", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1064", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1065", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1066", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1067", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1068", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1069", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1070", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1071", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1072", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1073", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1074", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1075", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1076", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1077", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1078", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1079", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1080", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1081", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1082", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1083", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1084", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1085", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1086", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1087", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1088", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1089", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1090", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1091", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1092", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1093", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1094", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1095", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1096", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1097", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1098", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1099", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1100", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1101", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1102", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1103", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1104", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1105", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1106", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1107", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1108", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1109", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1110", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1111", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1112", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1113", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1114", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1115", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1116", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1117", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1118", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1119", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1120", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1121", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1122", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1123", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1124", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1125", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1126", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1127", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1128", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1129", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1130", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1131", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1132", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1133", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1134", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1135", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1136", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1137", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1138", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1139", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1140", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1141", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1142", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1143", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1144", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1145", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1146", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1147", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1148", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1149", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1150", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1151", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1152", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1153", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1154", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1155", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1156", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1157", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1158", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1159", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1160", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1161", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1162", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1163", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1164", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1165", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1166", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1167", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1168", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1169", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1170", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1171", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1172", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1173", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1174", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1175", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1176", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1177", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1178", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1179", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1180", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1181", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1182", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1183", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1184", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1185", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1186", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1187", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1188", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1189", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1190", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1191", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1192", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1193", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1194", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1195", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1196", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1197", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1198", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1199", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1200", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1201", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1202", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1203", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1204", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1205", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1206", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1207", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1208", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1209", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1210", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1211", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1212", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1213", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1214", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1215", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1216", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1217", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1218", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1219", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1220", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1221", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1222", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1223", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1224", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1225", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1226", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1227", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1228", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1229", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1230", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1231", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1232", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1233", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1234", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1235", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1236", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1237", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1238", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1239", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1240", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1241", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1242", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1243", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1244", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1245", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1246", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1247", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1248", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1249", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1250", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1251", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1252", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1253", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1254", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1255", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1256", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1257", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1258", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1259", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1260", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1261", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1262", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1263", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1264", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1265", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1266", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1267", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1268", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1269", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1270", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1271", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1272", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1273", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1274", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1275", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1276", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1277", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1278", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1279", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1280", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1281", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1282", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1283", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1284", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1285", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1286", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1287", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1288", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1289", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1290", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1291", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1292", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1293", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1294", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1295", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1296", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1297", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1298", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1299", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1300", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1301", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1302", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1303", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1304", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1305", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1306", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1307", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1308", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1309", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1310", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1311", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1312", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1313", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1314", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1315", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1316", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1317", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1318", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1319", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1320", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1321", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1322", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1323", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1324", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1325", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1326", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1327", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1328", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1329", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1330", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1331", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1332", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1333", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1334", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1335", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1336", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1337", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1338", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1339", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1340", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1341", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1342", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1343", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1344", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1345", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1346", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1347", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1348", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1349", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1350", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1351", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1352", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1353", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1354", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1355", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1356", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1357", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1358", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1359", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1360", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1361", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1362", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1363", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1364", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1365", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1366", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1367", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1368", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1369", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1370", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1371", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1372", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1373", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1374", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1375", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1376", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1377", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1378", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1379", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1380", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1381", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1382", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1383", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1384", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1385", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1386", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1387", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1388", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1389", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1390", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1391", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1392", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1393", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1394", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1395", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1396", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1397", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1398", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1399", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1400", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1401", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1402", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1403", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1404", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1405", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1406", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1407", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1408", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1409", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1410", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1411", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1412", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1413", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1414", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1415", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1416", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1417", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1418", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1419", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1420", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1421", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1422", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1423", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1424", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1425", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1426", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1427", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1428", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1429", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1430", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1431", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1432", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1433", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1434", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1435", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1436", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1437", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1438", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1439", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1440", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1441", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1442", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1443", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1444", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1445", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1446", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1447", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1448", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1449", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1450", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1451", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1452", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1453", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1454", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1455", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1456", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1457", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1458", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1459", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1460", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1461", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1462", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1463", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1464", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1465", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1466", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1467", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1468", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1469", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1470", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1471", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1472", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1473", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1474", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1475", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1476", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1477", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1478", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1479", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1480", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1481", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1482", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1483", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1484", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1485", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1486", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1487", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1488", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1489", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1490", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1491", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1492", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1493", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1494", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1495", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1496", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1497", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1498", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1499", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1500", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1501", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1502", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1503", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1504", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1505", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1506", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1507", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1508", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1509", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1510", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1511", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1512", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1513", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1514", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1515", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1516", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1517", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1518", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1519", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1520", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1521", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1522", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1523", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1524", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1525", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1526", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1527", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1528", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1529", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1530", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1531", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1532", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1533", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1534", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1535", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1536", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1537", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1538", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1539", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1540", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1541", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1542", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1543", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1544", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1545", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1546", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1547", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1548", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1549", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1550", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1551", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1552", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1553", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1554", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1555", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1556", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1557", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1558", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1559", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1560", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1561", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1562", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1563", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1564", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1565", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1566", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1567", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1568", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1569", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1570", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1571", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1572", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1573", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1574", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1575", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1576", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1577", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1578", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1579", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1580", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1581", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1582", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1583", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1584", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1585", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1586", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1587", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1588", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1589", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1590", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1591", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1592", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1593", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1594", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1595", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1596", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1597", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1598", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1599", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1600", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1601", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1602", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1603", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1604", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1605", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1606", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1607", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1608", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1609", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1610", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1611", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1612", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1613", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1614", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1615", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1616", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1617", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1618", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1619", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1620", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1621", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1622", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1623", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1624", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1625", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1626", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1627", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1628", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1629", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1630", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1631", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1632", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1633", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1634", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1635", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1636", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1637", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1638", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1639", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1640", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1641", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1642", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1643", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1644", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1645", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1646", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1647", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1648", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1649", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1650", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1651", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1652", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1653", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1654", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1655", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1656", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1657", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1658", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1659", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1660", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1661", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1662", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1663", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1664", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1665", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1666", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1667", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1668", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1669", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1670", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1671", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1672", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1673", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1674", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1675", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1676", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1677", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1678", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1679", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1680", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1681", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1682", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1683", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1684", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1685", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1686", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1687", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1688", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1689", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1690", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1691", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1692", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1693", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1694", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1695", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1696", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1697", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1698", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1699", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1700", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1701", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1702", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1703", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1704", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1705", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1706", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1707", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1708", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1709", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1710", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1711", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1712", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1713", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1714", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1715", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1716", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1717", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1718", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1719", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1720", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1721", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1722", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1723", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1724", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1725", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1726", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1727", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1728", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1729", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1730", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1731", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1732", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1733", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1734", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1735", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1736", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1737", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1738", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1739", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1740", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1741", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1742", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1743", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1744", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1745", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1746", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1747", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1748", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1749", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1750", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1751", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1752", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1753", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1754", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1755", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1756", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1757", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1758", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1759", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1760", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1761", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1762", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1763", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1764", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1765", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1766", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1767", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1768", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1769", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1770", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1771", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1772", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1773", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1774", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1775", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1776", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1777", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1778", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1779", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1780", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1781", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1782", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1783", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1784", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1785", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1786", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1787", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1788", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1789", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1790", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1791", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1792", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1793", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1794", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1795", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1796", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1797", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1798", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1799", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1800", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1801", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1802", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1803", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1804", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1805", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1806", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1807", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1808", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1809", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1810", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1811", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1812", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1813", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1814", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1815", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1816", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1817", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1818", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1819", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1820", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1821", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1822", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1823", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1824", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1825", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1826", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1827", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1828", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1829", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1830", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1831", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1832", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1833", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1834", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1835", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1836", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1837", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1838", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1839", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1840", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1841", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1842", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1843", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1844", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1845", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1846", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1847", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1848", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1849", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1850", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1851", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1852", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1853", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1854", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1855", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1856", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1857", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1858", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1859", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1860", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1861", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1862", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1863", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1864", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1865", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1866", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1867", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1868", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1869", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1870", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1871", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1872", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1873", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1874", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1875", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1876", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1877", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1878", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1879", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1880", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1881", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1882", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1883", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1884", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1885", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1886", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1887", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1888", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1889", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1890", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1891", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1892", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1893", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1894", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1895", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1896", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1897", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1898", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1899", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1900", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1901", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1902", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1903", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1904", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1905", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1906", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1907", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1908", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1909", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1910", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1911", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1912", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1913", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1914", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1915", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1916", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1917", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1918", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1919", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1920", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1921", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1922", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1923", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1924", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1925", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1926", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1927", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1928", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1929", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1930", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1931", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1932", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1933", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1934", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1935", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1936", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1937", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1938", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1939", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1940", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1941", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1942", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1943", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1944", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1945", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1946", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1947", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1948", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1949", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1950", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1951", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1952", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1953", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1954", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1955", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1956", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1957", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1958", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1959", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1960", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1961", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1962", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1963", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1964", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1965", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1966", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1967", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1968", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1969", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1970", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1971", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1972", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1973", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1974", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1975", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1976", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1977", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1978", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1979", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1980", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_1981", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1982", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1983", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1984", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1985", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1986", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1987", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1988", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1989", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_1990", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1991", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1992", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1993", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_1994", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1995", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1996", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_1997", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_1998", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_1999", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2000", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2001", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2002", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2003", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2004", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2005", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2006", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2007", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2008", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2009", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2010", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2011", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2012", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2013", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2014", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2015", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2016", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2017", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2018", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2019", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2020", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2021", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2022", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2023", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2024", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2025", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2026", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2027", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2028", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2029", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2030", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2031", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2032", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2033", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2034", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2035", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2036", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2037", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2038", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2039", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2040", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2041", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2042", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2043", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2044", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2045", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2046", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2047", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2048", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2049", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2050", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2051", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2052", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2053", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2054", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2055", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2056", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2057", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2058", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2059", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2060", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2061", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2062", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2063", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2064", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2065", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2066", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2067", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2068", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2069", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2070", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2071", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2072", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2073", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2074", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2075", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2076", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2077", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2078", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2079", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2080", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2081", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2082", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2083", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2084", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2085", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2086", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2087", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2088", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2089", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2090", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2091", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2092", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2093", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2094", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2095", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2096", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2097", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2098", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2099", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2100", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2101", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2102", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2103", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2104", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2105", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2106", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2107", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2108", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2109", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2110", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2111", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2112", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2113", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2114", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2115", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2116", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2117", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2118", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2119", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2120", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2121", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2122", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2123", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2124", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2125", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2126", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2127", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2128", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2129", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2130", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2131", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2132", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2133", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2134", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2135", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2136", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2137", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2138", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2139", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2140", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2141", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2142", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2143", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2144", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2145", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2146", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2147", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2148", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2149", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2150", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2151", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2152", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2153", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2154", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2155", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2156", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2157", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2158", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2159", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2160", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2161", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2162", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2163", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2164", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2165", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2166", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2167", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2168", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2169", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2170", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2171", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2172", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2173", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2174", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2175", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2176", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2177", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2178", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2179", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2180", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2181", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2182", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2183", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2184", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2185", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2186", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2187", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2188", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2189", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2190", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2191", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2192", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2193", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2194", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2195", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2196", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2197", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2198", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2199", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2200", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2201", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2202", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2203", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2204", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2205", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2206", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2207", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2208", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2209", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2210", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2211", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2212", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2213", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2214", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2215", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2216", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2217", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2218", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2219", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2220", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2221", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2222", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2223", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2224", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2225", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2226", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2227", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2228", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2229", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2230", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2231", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2232", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2233", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2234", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2235", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2236", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2237", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2238", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2239", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2240", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2241", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2242", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2243", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2244", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2245", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2246", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2247", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2248", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2249", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2250", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2251", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2252", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2253", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2254", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2255", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2256", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2257", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2258", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2259", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2260", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2261", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2262", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2263", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2264", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2265", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2266", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2267", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2268", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2269", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2270", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2271", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2272", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2273", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2274", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2275", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2276", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2277", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2278", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2279", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2280", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2281", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2282", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2283", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2284", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2285", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2286", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2287", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2288", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2289", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2290", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2291", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2292", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2293", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2294", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2295", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2296", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2297", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2298", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2299", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2300", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2301", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2302", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2303", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2304", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2305", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2306", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2307", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2308", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2309", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2310", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2311", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2312", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2313", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2314", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2315", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2316", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2317", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2318", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2319", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2320", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2321", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2322", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2323", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2324", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2325", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2326", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2327", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2328", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2329", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2330", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2331", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2332", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2333", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2334", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2335", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2336", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2337", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2338", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2339", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2340", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2341", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2342", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2343", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2344", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2345", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2346", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2347", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2348", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2349", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2350", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2351", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2352", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2353", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2354", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2355", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2356", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2357", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2358", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2359", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2360", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2361", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2362", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2363", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2364", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2365", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2366", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2367", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2368", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2369", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2370", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2371", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2372", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2373", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2374", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2375", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2376", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2377", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2378", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2379", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2380", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2381", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2382", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2383", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2384", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2385", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2386", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2387", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2388", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2389", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2390", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2391", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2392", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2393", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2394", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2395", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2396", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2397", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2398", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2399", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2400", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2401", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2402", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2403", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2404", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2405", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2406", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2407", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2408", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2409", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2410", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2411", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2412", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2413", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2414", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2415", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2416", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2417", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2418", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2419", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2420", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2421", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2422", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2423", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2424", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2425", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2426", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2427", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2428", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2429", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2430", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2431", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2432", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2433", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2434", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2435", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2436", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2437", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2438", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2439", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2440", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2441", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2442", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2443", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2444", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2445", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2446", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2447", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2448", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2449", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2450", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2451", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2452", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2453", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2454", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2455", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2456", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2457", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2458", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2459", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2460", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2461", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2462", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2463", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2464", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2465", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2466", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2467", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2468", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2469", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2470", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2471", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2472", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2473", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2474", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2475", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2476", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2477", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2478", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2479", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2480", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2481", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2482", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2483", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2484", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2485", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2486", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2487", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2488", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2489", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2490", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2491", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2492", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2493", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2494", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2495", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2496", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2497", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2498", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2499", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2500", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2501", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2502", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2503", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2504", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2505", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2506", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2507", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2508", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2509", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2510", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2511", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2512", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2513", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2514", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2515", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2516", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2517", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2518", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2519", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2520", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2521", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2522", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2523", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2524", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2525", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2526", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2527", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2528", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2529", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2530", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2531", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2532", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2533", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2534", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2535", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2536", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2537", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2538", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2539", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2540", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2541", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2542", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2543", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2544", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2545", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2546", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2547", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2548", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2549", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2550", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2551", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2552", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2553", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2554", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2555", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2556", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2557", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2558", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2559", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2560", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2561", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2562", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2563", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2564", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2565", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2566", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2567", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2568", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2569", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2570", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2571", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2572", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2573", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2574", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2575", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2576", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2577", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2578", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2579", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2580", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2581", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2582", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2583", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2584", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2585", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2586", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2587", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2588", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2589", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2590", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2591", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2592", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2593", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2594", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2595", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2596", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2597", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2598", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2599", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2600", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2601", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2602", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2603", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2604", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2605", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2606", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2607", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2608", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2609", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2610", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2611", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2612", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2613", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2614", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2615", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2616", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2617", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2618", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2619", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2620", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2621", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2622", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2623", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2624", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2625", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2626", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2627", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2628", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2629", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2630", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2631", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2632", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2633", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2634", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2635", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2636", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2637", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2638", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2639", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2640", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2641", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2642", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2643", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2644", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2645", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2646", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2647", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2648", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2649", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2650", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2651", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2652", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2653", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2654", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2655", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2656", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2657", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2658", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2659", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2660", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2661", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2662", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2663", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2664", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2665", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2666", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2667", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2668", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2669", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2670", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2671", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2672", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2673", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2674", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2675", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2676", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2677", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2678", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2679", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2680", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2681", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2682", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2683", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2684", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2685", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2686", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2687", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2688", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2689", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2690", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2691", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2692", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2693", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2694", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2695", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2696", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2697", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2698", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2699", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2700", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2701", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2702", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2703", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2704", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2705", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2706", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2707", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2708", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2709", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2710", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2711", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2712", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2713", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2714", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2715", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2716", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2717", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2718", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2719", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2720", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2721", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2722", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2723", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2724", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2725", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2726", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2727", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2728", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2729", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2730", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2731", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2732", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2733", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2734", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2735", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2736", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2737", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2738", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2739", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2740", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2741", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2742", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2743", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2744", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2745", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2746", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2747", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2748", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2749", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2750", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2751", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2752", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2753", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2754", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2755", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2756", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2757", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2758", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2759", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2760", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2761", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2762", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2763", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2764", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2765", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2766", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2767", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2768", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2769", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2770", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2771", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2772", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2773", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2774", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2775", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2776", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2777", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2778", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2779", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2780", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2781", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2782", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2783", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2784", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2785", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2786", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2787", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2788", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2789", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2790", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2791", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2792", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2793", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2794", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2795", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2796", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2797", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2798", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2799", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2800", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2801", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2802", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2803", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2804", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2805", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2806", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2807", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2808", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2809", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2810", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2811", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2812", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2813", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2814", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2815", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2816", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2817", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2818", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2819", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2820", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2821", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2822", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2823", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2824", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2825", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2826", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2827", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2828", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2829", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2830", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2831", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2832", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2833", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2834", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2835", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2836", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2837", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2838", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2839", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2840", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2841", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2842", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2843", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2844", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2845", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2846", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2847", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2848", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2849", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2850", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2851", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2852", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2853", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2854", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2855", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2856", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2857", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2858", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2859", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2860", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2861", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2862", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2863", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2864", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2865", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2866", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2867", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2868", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2869", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2870", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2871", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2872", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2873", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2874", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2875", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2876", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2877", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2878", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2879", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2880", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2881", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2882", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2883", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2884", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2885", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2886", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2887", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2888", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2889", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2890", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2891", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2892", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2893", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2894", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2895", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2896", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2897", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2898", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2899", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2900", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2901", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2902", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2903", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2904", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2905", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2906", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2907", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2908", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2909", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2910", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2911", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2912", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2913", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2914", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2915", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2916", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2917", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2918", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2919", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2920", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2921", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2922", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2923", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2924", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2925", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2926", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2927", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2928", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2929", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2930", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2931", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2932", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2933", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2934", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2935", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2936", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2937", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2938", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2939", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2940", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2941", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2942", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2943", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2944", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2945", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2946", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2947", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2948", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2949", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2950", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2951", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2952", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2953", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2954", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2955", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2956", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2957", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2958", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2959", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2960", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2961", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2962", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2963", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2964", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2965", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2966", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2967", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2968", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2969", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2970", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2971", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2972", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2973", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2974", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2975", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2976", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2977", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2978", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2979", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2980", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2981", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2982", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2983", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2984", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2985", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2986", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_2987", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2988", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_2989", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2990", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2991", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2992", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_2993", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_2994", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2995", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2996", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2997", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_2998", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_2999", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3000", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3001", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3002", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3003", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3004", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3005", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3006", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3007", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3008", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3009", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3010", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3011", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3012", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3013", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3014", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3015", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3016", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3017", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3018", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3019", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3020", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3021", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3022", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3023", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3024", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3025", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3026", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3027", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3028", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3029", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3030", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3031", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3032", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3033", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3034", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3035", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3036", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3037", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3038", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3039", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3040", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3041", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3042", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3043", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3044", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3045", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3046", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3047", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3048", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3049", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3050", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3051", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3052", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3053", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3054", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3055", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3056", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3057", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3058", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3059", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3060", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3061", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3062", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3063", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3064", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3065", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3066", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3067", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3068", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3069", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3070", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3071", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3072", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3073", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3074", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3075", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3076", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3077", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3078", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3079", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3080", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3081", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3082", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3083", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3084", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3085", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3086", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3087", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3088", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3089", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3090", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3091", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3092", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3093", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3094", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3095", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3096", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3097", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3098", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3099", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3100", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3101", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3102", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3103", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3104", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3105", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3106", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3107", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3108", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3109", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3110", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3111", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3112", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3113", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3114", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3115", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3116", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3117", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3118", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3119", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3120", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3121", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3122", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3123", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3124", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3125", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3126", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3127", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3128", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3129", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3130", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3131", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3132", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3133", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3134", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3135", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3136", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3137", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3138", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3139", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3140", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3141", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3142", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3143", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3144", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3145", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3146", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3147", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3148", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3149", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3150", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3151", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3152", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3153", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3154", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3155", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3156", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3157", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3158", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3159", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3160", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3161", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3162", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3163", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3164", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3165", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3166", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3167", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3168", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3169", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3170", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3171", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3172", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3173", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3174", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3175", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3176", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3177", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3178", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3179", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3180", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3181", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3182", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3183", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3184", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3185", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3186", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3187", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3188", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3189", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3190", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3191", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3192", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3193", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3194", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3195", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3196", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3197", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3198", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3199", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3200", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3201", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3202", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3203", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3204", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3205", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3206", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3207", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3208", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3209", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3210", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3211", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3212", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3213", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3214", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3215", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3216", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3217", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3218", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3219", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3220", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3221", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3222", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3223", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3224", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3225", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3226", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3227", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3228", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3229", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3230", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3231", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3232", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3233", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3234", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3235", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3236", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3237", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3238", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3239", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3240", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3241", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3242", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3243", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3244", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3245", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3246", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3247", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3248", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3249", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3250", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3251", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3252", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3253", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3254", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3255", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3256", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3257", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3258", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3259", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3260", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3261", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3262", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3263", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3264", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3265", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3266", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3267", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3268", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3269", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3270", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3271", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3272", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3273", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3274", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3275", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3276", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3277", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3278", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3279", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3280", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3281", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3282", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3283", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3284", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3285", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3286", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3287", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3288", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3289", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3290", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3291", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3292", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3293", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3294", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3295", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3296", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3297", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3298", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3299", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3300", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3301", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3302", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3303", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3304", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3305", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3306", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3307", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3308", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3309", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3310", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3311", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3312", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3313", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3314", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3315", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3316", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3317", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3318", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3319", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3320", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3321", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3322", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3323", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3324", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3325", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3326", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3327", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3328", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3329", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3330", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3331", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3332", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3333", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3334", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3335", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3336", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3337", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3338", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3339", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3340", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3341", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3342", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3343", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3344", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3345", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3346", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3347", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3348", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3349", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3350", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3351", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3352", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3353", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3354", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3355", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3356", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3357", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3358", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3359", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3360", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3361", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3362", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3363", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3364", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3365", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3366", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3367", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3368", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3369", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3370", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3371", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3372", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3373", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3374", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3375", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3376", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3377", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3378", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3379", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3380", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3381", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3382", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3383", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3384", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3385", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3386", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3387", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3388", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3389", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3390", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3391", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3392", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3393", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3394", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3395", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3396", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3397", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3398", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3399", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3400", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3401", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3402", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3403", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3404", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3405", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3406", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3407", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3408", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3409", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3410", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3411", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3412", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3413", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3414", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3415", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3416", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3417", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3418", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3419", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3420", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3421", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3422", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3423", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3424", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3425", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3426", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3427", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3428", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3429", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3430", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3431", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3432", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3433", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3434", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3435", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3436", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3437", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3438", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3439", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3440", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3441", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3442", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3443", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3444", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3445", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3446", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3447", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3448", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3449", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3450", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3451", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3452", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3453", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3454", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3455", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3456", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3457", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3458", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3459", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3460", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3461", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3462", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3463", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3464", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3465", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3466", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3467", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3468", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3469", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3470", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3471", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3472", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3473", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3474", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3475", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3476", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3477", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3478", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3479", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3480", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3481", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3482", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3483", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3484", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3485", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3486", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3487", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3488", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3489", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3490", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3491", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3492", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3493", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3494", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3495", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3496", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3497", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3498", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3499", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3500", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3501", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3502", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3503", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3504", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3505", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3506", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3507", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3508", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3509", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3510", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3511", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3512", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3513", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3514", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3515", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3516", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3517", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3518", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3519", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3520", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3521", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3522", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3523", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3524", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3525", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3526", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3527", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3528", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3529", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3530", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3531", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3532", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3533", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3534", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3535", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3536", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3537", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3538", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3539", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3540", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3541", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3542", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3543", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3544", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3545", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3546", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3547", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3548", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3549", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3550", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3551", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3552", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3553", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3554", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3555", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3556", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3557", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3558", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3559", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3560", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3561", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3562", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3563", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3564", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3565", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3566", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3567", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3568", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3569", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3570", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3571", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3572", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3573", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3574", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3575", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3576", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3577", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3578", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3579", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3580", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3581", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3582", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3583", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3584", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3585", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3586", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3587", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3588", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3589", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3590", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3591", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3592", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3593", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3594", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3595", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3596", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3597", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3598", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3599", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3600", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3601", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3602", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3603", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3604", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3605", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3606", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3607", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3608", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3609", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3610", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3611", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3612", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3613", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3614", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3615", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3616", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3617", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3618", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3619", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3620", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3621", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3622", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3623", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3624", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3625", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3626", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3627", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3628", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3629", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3630", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3631", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3632", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3633", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3634", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3635", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3636", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3637", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3638", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3639", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3640", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3641", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3642", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3643", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3644", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3645", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3646", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3647", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3648", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3649", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3650", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3651", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3652", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3653", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3654", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3655", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3656", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3657", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3658", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3659", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3660", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3661", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3662", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3663", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3664", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3665", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3666", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3667", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3668", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3669", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3670", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3671", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3672", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3673", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3674", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3675", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3676", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3677", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3678", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3679", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3680", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3681", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3682", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3683", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3684", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3685", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3686", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3687", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3688", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3689", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3690", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3691", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3692", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3693", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3694", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3695", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3696", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3697", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3698", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3699", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3700", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3701", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3702", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3703", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3704", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3705", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3706", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3707", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3708", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3709", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3710", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3711", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3712", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3713", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3714", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3715", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3716", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3717", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3718", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3719", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3720", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3721", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3722", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3723", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3724", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3725", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3726", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3727", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3728", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3729", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3730", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3731", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3732", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3733", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3734", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3735", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3736", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3737", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3738", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3739", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3740", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3741", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3742", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3743", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3744", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3745", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3746", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3747", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3748", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3749", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3750", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3751", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3752", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3753", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3754", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3755", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3756", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3757", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3758", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3759", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3760", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3761", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3762", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3763", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3764", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3765", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3766", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3767", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3768", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3769", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3770", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3771", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3772", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3773", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3774", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3775", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3776", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3777", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3778", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3779", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3780", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3781", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3782", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3783", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3784", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3785", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3786", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3787", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3788", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3789", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3790", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3791", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3792", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3793", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3794", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3795", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3796", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3797", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3798", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3799", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3800", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3801", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3802", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3803", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3804", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3805", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3806", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3807", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3808", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3809", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3810", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3811", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3812", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3813", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3814", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3815", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3816", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3817", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3818", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3819", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3820", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3821", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3822", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3823", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3824", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3825", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3826", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3827", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3828", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3829", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3830", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3831", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3832", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3833", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3834", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3835", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3836", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3837", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3838", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3839", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3840", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3841", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3842", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3843", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3844", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3845", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3846", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3847", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3848", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3849", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3850", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3851", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3852", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3853", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3854", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3855", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3856", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3857", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3858", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3859", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3860", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3861", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3862", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3863", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3864", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3865", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3866", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3867", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3868", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3869", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3870", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3871", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3872", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3873", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3874", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3875", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3876", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3877", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3878", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3879", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3880", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3881", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3882", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3883", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3884", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3885", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3886", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3887", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3888", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3889", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3890", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3891", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3892", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3893", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3894", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3895", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3896", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3897", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3898", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3899", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3900", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3901", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3902", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3903", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3904", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3905", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3906", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3907", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3908", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3909", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3910", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3911", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3912", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3913", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3914", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3915", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3916", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3917", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3918", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3919", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3920", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3921", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3922", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3923", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3924", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3925", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3926", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3927", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3928", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3929", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3930", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3931", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3932", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3933", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3934", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3935", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3936", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3937", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3938", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3939", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3940", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3941", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3942", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3943", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3944", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3945", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3946", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3947", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3948", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3949", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3950", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3951", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3952", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3953", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3954", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3955", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3956", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3957", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3958", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3959", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3960", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3961", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3962", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3963", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3964", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3965", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3966", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3967", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3968", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3969", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3970", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3971", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3972", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3973", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3974", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3975", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3976", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3977", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3978", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3979", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3980", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3981", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3982", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3983", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3984", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3985", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3986", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_3987", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3988", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3989", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3990", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3991", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3992", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3993", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_3994", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3995", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_3996", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_3997", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_3998", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_3999", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4000", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4001", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4002", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4003", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4004", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4005", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4006", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4007", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4008", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4009", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4010", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4011", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4012", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4013", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4014", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4015", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4016", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4017", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4018", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4019", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4020", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4021", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4022", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4023", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4024", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4025", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4026", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4027", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4028", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4029", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4030", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4031", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4032", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4033", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4034", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4035", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4036", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4037", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4038", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4039", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4040", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4041", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4042", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4043", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4044", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4045", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4046", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4047", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4048", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4049", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4050", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4051", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4052", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4053", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4054", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4055", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4056", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4057", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4058", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4059", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4060", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4061", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4062", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4063", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4064", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4065", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4066", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4067", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4068", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4069", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4070", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4071", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4072", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4073", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4074", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4075", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4076", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4077", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4078", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4079", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4080", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4081", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4082", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4083", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4084", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4085", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4086", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4087", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4088", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4089", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4090", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4091", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4092", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4093", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4094", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4095", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4096", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4097", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4098", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4099", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4100", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4101", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4102", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4103", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4104", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4105", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4106", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4107", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4108", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4109", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4110", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4111", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4112", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4113", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4114", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4115", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4116", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4117", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4118", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4119", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4120", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4121", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4122", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4123", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4124", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4125", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4126", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4127", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4128", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4129", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4130", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4131", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4132", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4133", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4134", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4135", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4136", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4137", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4138", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4139", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4140", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4141", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4142", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4143", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4144", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4145", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4146", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4147", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4148", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4149", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4150", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4151", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4152", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4153", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4154", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4155", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4156", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4157", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4158", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4159", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4160", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4161", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4162", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4163", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4164", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4165", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4166", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4167", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4168", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4169", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4170", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4171", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4172", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4173", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4174", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4175", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4176", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4177", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4178", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4179", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4180", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4181", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4182", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4183", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4184", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4185", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4186", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4187", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4188", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4189", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4190", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4191", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4192", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4193", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4194", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4195", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4196", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4197", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4198", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4199", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4200", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4201", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4202", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4203", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4204", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4205", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4206", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4207", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4208", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4209", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4210", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4211", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4212", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4213", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4214", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4215", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4216", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4217", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4218", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4219", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4220", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4221", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4222", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4223", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4224", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4225", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4226", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4227", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4228", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4229", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4230", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4231", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4232", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4233", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4234", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4235", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4236", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4237", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4238", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4239", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4240", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4241", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4242", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4243", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4244", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4245", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4246", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4247", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4248", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4249", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4250", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4251", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4252", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4253", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4254", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4255", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4256", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4257", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4258", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4259", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4260", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4261", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4262", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4263", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4264", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4265", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4266", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4267", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4268", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4269", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4270", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4271", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4272", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4273", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4274", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4275", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4276", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4277", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4278", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4279", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4280", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4281", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4282", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4283", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4284", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4285", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4286", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4287", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4288", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4289", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4290", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4291", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4292", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4293", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4294", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4295", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4296", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4297", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4298", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4299", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4300", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4301", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4302", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4303", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4304", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4305", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4306", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4307", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4308", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4309", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4310", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4311", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4312", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4313", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4314", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4315", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4316", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4317", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4318", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4319", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4320", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4321", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4322", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4323", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4324", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4325", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4326", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4327", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4328", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4329", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4330", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4331", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4332", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4333", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4334", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4335", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4336", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4337", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4338", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4339", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4340", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4341", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4342", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4343", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4344", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4345", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4346", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4347", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4348", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4349", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4350", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4351", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4352", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4353", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4354", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4355", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4356", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4357", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4358", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4359", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4360", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4361", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4362", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4363", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4364", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4365", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4366", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4367", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4368", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4369", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4370", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4371", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4372", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4373", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4374", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4375", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4376", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4377", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4378", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4379", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4380", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4381", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4382", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4383", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4384", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4385", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4386", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4387", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4388", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4389", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4390", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4391", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4392", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4393", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4394", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4395", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4396", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4397", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4398", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4399", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4400", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4401", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4402", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4403", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4404", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4405", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4406", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4407", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4408", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4409", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4410", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4411", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4412", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4413", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4414", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4415", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4416", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4417", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4418", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4419", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4420", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4421", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4422", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4423", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4424", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4425", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4426", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4427", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4428", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4429", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4430", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4431", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4432", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4433", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4434", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4435", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4436", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4437", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4438", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4439", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4440", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4441", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4442", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4443", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4444", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4445", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4446", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4447", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4448", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4449", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4450", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4451", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4452", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4453", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4454", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4455", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4456", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4457", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4458", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4459", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4460", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4461", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4462", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4463", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4464", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4465", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4466", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4467", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4468", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4469", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4470", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4471", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4472", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4473", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4474", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4475", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4476", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4477", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4478", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4479", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4480", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4481", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4482", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4483", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4484", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4485", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4486", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4487", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4488", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4489", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4490", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4491", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4492", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4493", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4494", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4495", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4496", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4497", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4498", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4499", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4500", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4501", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4502", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4503", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4504", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4505", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4506", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4507", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4508", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4509", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4510", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4511", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4512", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4513", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4514", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4515", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4516", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4517", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4518", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4519", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4520", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4521", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4522", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4523", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4524", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4525", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4526", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4527", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4528", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4529", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4530", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4531", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4532", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4533", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4534", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4535", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4536", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4537", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4538", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4539", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4540", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4541", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4542", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4543", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4544", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4545", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4546", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4547", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4548", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4549", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4550", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4551", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4552", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4553", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4554", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4555", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4556", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4557", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4558", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4559", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4560", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4561", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4562", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4563", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4564", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4565", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4566", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4567", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4568", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4569", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4570", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4571", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4572", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4573", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4574", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4575", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4576", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4577", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4578", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4579", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4580", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4581", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4582", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4583", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4584", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4585", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4586", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4587", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4588", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4589", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4590", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4591", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4592", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4593", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4594", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4595", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4596", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4597", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4598", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4599", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4600", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4601", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4602", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4603", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4604", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4605", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4606", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4607", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4608", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4609", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4610", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4611", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4612", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4613", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4614", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4615", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4616", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4617", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4618", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4619", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4620", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4621", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4622", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4623", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4624", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4625", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4626", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4627", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4628", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4629", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4630", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4631", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4632", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4633", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4634", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4635", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4636", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4637", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4638", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4639", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4640", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4641", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4642", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4643", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4644", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4645", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4646", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4647", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4648", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4649", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4650", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4651", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4652", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4653", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4654", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4655", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4656", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4657", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4658", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4659", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4660", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4661", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4662", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4663", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4664", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4665", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4666", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4667", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4668", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4669", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4670", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4671", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4672", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4673", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4674", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4675", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4676", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4677", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4678", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4679", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4680", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4681", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4682", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4683", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4684", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4685", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4686", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4687", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4688", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4689", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4690", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4691", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4692", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4693", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4694", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4695", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4696", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4697", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4698", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4699", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4700", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4701", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4702", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4703", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4704", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4705", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4706", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4707", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4708", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4709", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4710", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4711", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4712", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4713", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4714", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4715", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4716", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4717", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4718", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4719", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4720", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4721", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4722", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4723", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4724", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4725", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4726", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4727", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4728", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4729", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4730", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4731", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4732", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4733", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4734", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4735", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4736", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4737", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4738", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4739", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4740", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4741", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4742", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4743", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4744", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4745", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4746", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4747", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4748", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4749", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4750", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4751", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4752", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4753", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4754", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4755", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4756", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4757", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4758", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4759", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4760", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4761", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4762", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4763", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4764", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4765", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4766", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4767", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4768", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4769", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4770", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4771", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4772", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4773", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4774", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4775", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4776", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4777", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4778", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4779", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4780", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4781", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4782", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4783", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4784", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4785", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4786", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4787", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4788", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4789", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4790", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4791", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4792", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4793", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4794", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4795", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4796", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4797", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4798", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4799", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4800", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4801", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4802", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4803", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4804", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4805", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4806", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4807", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4808", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4809", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4810", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4811", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4812", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4813", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4814", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4815", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4816", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4817", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4818", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4819", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4820", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4821", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4822", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4823", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4824", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4825", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4826", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4827", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4828", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4829", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4830", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4831", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4832", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4833", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4834", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4835", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4836", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4837", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4838", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4839", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4840", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4841", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4842", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4843", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4844", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4845", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4846", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4847", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4848", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4849", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4850", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4851", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4852", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4853", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4854", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4855", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4856", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4857", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4858", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4859", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4860", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4861", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4862", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4863", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4864", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4865", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4866", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4867", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4868", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4869", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4870", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4871", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4872", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4873", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4874", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4875", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4876", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4877", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4878", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4879", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4880", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4881", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4882", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4883", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4884", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4885", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4886", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4887", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4888", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4889", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4890", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4891", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4892", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4893", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4894", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4895", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4896", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4897", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4898", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4899", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4900", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4901", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4902", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4903", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4904", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4905", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4906", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4907", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4908", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4909", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4910", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4911", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4912", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4913", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4914", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4915", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4916", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4917", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4918", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4919", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4920", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4921", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4922", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4923", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4924", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4925", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4926", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4927", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4928", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4929", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4930", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4931", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4932", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4933", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4934", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4935", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4936", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4937", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4938", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4939", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4940", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4941", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4942", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4943", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4944", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4945", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4946", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4947", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4948", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4949", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4950", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4951", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4952", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4953", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4954", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4955", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4956", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4957", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4958", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4959", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4960", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4961", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4962", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4963", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4964", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4965", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4966", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4967", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4968", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4969", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4970", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4971", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4972", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4973", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4974", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4975", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4976", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4977", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4978", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4979", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4980", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4981", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4982", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4983", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4984", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4985", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4986", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4987", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4988", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4989", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4990", + "clinical_note": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "M25.561" + ] + }, + "specialty": "primary_care", + "template_type": "knee_pain" + }, + { + "id": "note_4991", + "clinical_note": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "ground_truth_codes": { + "cpt": [ + "99214" + ], + "icd": [ + "E11.9" + ] + }, + "specialty": "primary_care", + "template_type": "diabetes_management" + }, + { + "id": "note_4992", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4993", + "clinical_note": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "ground_truth_codes": { + "cpt": [ + "99393" + ], + "icd": [ + "Z00.129" + ] + }, + "specialty": "primary_care", + "template_type": "well_child_visit" + }, + { + "id": "note_4994", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4995", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4996", + "clinical_note": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "ground_truth_codes": { + "cpt": [ + "99395" + ], + "icd": [ + "Z00.00" + ] + }, + "specialty": "primary_care", + "template_type": "annual_physical" + }, + { + "id": "note_4997", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + }, + { + "id": "note_4998", + "clinical_note": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "J06.9" + ] + }, + "specialty": "primary_care", + "template_type": "uri_visit" + }, + { + "id": "note_4999", + "clinical_note": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "ground_truth_codes": { + "cpt": [ + "99213" + ], + "icd": [ + "I10" + ] + }, + "specialty": "primary_care", + "template_type": "hypertension_followup" + } +] \ No newline at end of file