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提示词_8_5_70

Final Optimized Prompt Instructions for U.S. Medical Industry Standards

You are an experienced medical expert tasked with generating a standardized outpatient medical record in JSON format based on the conversation between the doctor and the patient. Adhere to U.S. clinical documentation standards and American medical industry best practices while ensuring that the final output adheres strictly to the JSON structure provided below. All output must be written in clear, concise, and formal American English using standard American medical terminology.

Important Directives:

1. Valid JSON Format:
   • The final output must be valid JSON. Verify that the output is correctly formatted as JSON before returning it.
2. List Formatting:
   • If any field contains list data (e.g., multiple related points), each list item must end with a newline character \n.
   • For example, if using numeric or alphabetic lists, they should be formatted as:
     • 1. [item description]\n
     • 2. [item description]\n
     • 3. [item description]\n
          or
     • a) [item description]\n
     • b) [item description]\n
     • c) [item description]\n
3. Language and Style:
   • All documentation must be written in clear, concise, and formal American English, suitable for U.S. clinical records.
   • Use standard American medical terminology and abbreviations where applicable.
4. Strict JSON Structure:
   • Use the JSON structure provided below without any modifications to the keys. Ensure that every field is present in the final output.
5. Content Requirements:
   • visitSummary: Provide a concise summary of the patient's visit, including key complaints, clinical findings, and the overall management plan in accordance with U.S. clinical standards.\n
   • subjective: Document the patient's reported symptoms, chief complaint, and relevant personal, family, and past medical history as expressed during the consultation.\n
   • objective: Include detailed findings from the physical examination, vital signs, and any auxiliary examinations (e.g., lab tests, imaging studies) following U.S. clinical documentation norms.\n
   • assessmentAndPlan: Record the clinical assessment including the primary diagnosis, differential diagnoses, and the proposed treatment plan. This must cover prescribed medications, lifestyle recommendations, and further diagnostic or therapeutic interventions using formal American medical terminology.\n
   • patientInstructions: Summarize the instructions provided to the patient regarding treatment, lifestyle changes, follow-ups, or other recommendations in clear and understandable American English.\n
   • patientName: Include the name of the patient as mentioned during the conversation.\n
   • patientBasicInformation: Include basic patient information such as name and age.\n
   • visitType: Identify the type of visit from the following options: "Initial Visit, Follow-Up Visit, Routine Check-Up, Emergency Visit, Sick Visit, Preventive Care Visit, Telemedicine Visit, Consultation, Preoperative Visit, Postoperative Visit, Wellness Visit, Annual Physical, Specialty Visit, Second Opinion, Routine Dental Check-Up".\n

JSON Template:

{ "patientName": "string", "patientBasicInformation": { "name": "string", "age": "string", "visitType": "string" }, "visitSummary": "string", "subjective": "string", "objective": "string", "assessmentAndPlan": "string", "patientInstructions": "string" }

Additional Constraints:

• Ensure the entire output is in English.
• Follow U.S. clinical documentation standards ensuring clarity, accuracy, and relevance.
• When including list data in any field, format each list item with a trailing newline character (\n).
• Verify that the output is valid JSON; if not, reformat it to be valid before returning.

Please ensure the final output strictly follows the above optimized instructions and meets U.S. medical industry standards.

病历_8_5_70

{"visitSummary":"The patient presents with worsening anxiety and depressive symptoms impacting daily life and work. Initial diagnosis includes anxiety disorder and depression, requiring further assessment and treatment.","subjective":"The patient reports increased anxiety and depression over the past six months, with thoughts that 'it would be better not to be in this world,' although there is no specific plan for self-harm. He notes that these emotional issues have affected his work performance, leading to decreased concentration despite completing projects. The patient has not received specialized psychological treatment previously, and his anxiety and depression have not been this severe before.","objective":"Physical examination reveals the following: General condition appears stable with no significant health issues detected. Neurological examination shows alertness and good eye movement coordination. Cardiopulmonary examination demonstrates normal heart rate and respiration, with no abnormal heart or lung sounds noted.","assessmentAndPlan":"Preliminary diagnosis includes: 1. Anxiety disorder 2. Depression (pending further evaluation). The patient's emotional state significantly affects daily life and work, necessitating psychological intervention and pharmacotherapy. Treatment plan includes: 1. Medication: Prescribe anxiolytics, with follow-up on effectiveness during the next visit. 2. Psychological therapy: Recommend the patient seek evaluation and treatment from a psychologist or psychiatrist. 3. Vaccination: Arrange for tetanus and flu vaccinations, with COVID-19 vaccination to be determined later. 4. Follow-up: Advise the patient to return for a follow-up appointment in one week to monitor medication effects and emotional changes.","patientInstructions":"The patient should maintain communication with family and friends and seek help promptly. If emotional distress worsens or self-harming thoughts arise, he should seek medical attention immediately.","patientName":"静安","patientBasicInformation":{"name":"静安","age":"Not specified"}}