Expand ROS/PE: pertinent negatives for WNL, clinical descriptions for abnormal

- WNL/Normal systems now expand to 1-3 specific pertinent negatives instead of
  just "WNL" — varies each time, relates to chief complaint and differential
  (e.g., Skin: "no rash, no petechiae, no bruising" instead of "WNL")
- Abnormal systems: AI expands physician's brief note into clinical description
  favoring most common presentation, adds only 1-2 related pertinent negatives
  (e.g., "pimples on face" → "inflammatory papules on bilateral cheeks...")
- Format function now passes system domain details for context
- Rules applied to well visit (full + short) and sick visit prompts

public/js/shadess.js

@@ -500,8 +500,15 @@
       if (!status) return;
       hasAny = true;
       var note = dataObj[sys.key + '_note'] || '';
-      var statusLabel = status === 'wnl' ? 'WNL' : status === 'abnormal' ? 'Abnormal' : 'Not reviewed';
-      lines.push('  ' + sys.label + ': ' + statusLabel + (note ? ' — ' + note : ''));
+      if (status === 'wnl') {
+        // WNL — tell AI to expand with pertinent negatives, include domain details for context
+        lines.push('  ' + sys.label + ': NORMAL [domain: ' + sys.detail + ']');
+      } else if (status === 'abnormal') {
+        // Abnormal — user's note is the finding; AI should expand/describe it
+        lines.push('  ' + sys.label + ': ABNORMAL' + (note ? ' — ' + note : '') + ' [domain: ' + sys.detail + ']');
+      } else {
+        lines.push('  ' + sys.label + ': Not reviewed');
+      }
     });
     return hasAny ? lines.join('\n') : '';
   };

src/utils/prompts.js

@@ -14,6 +14,39 @@ CRITICAL RULES FOR ALL OUTPUTS:
 - Use plain numbered lists (1. 2. 3.) or plain line breaks for structure, never markdown bullets
 `;
 
+const ROS_PE_RULES = `
+REVIEW OF SYSTEMS AND PHYSICAL EXAM EXPANSION RULES:
+When ROS or PE data is provided with NORMAL or ABNORMAL status:
+
+For NORMAL systems:
+- Do NOT simply write "WNL" or "within normal limits" — expand each into 1-3 specific pertinent negatives
+- Vary the negatives each time; do not repeat the same boilerplate
+- Choose negatives that are clinically relevant to the patient's age, chief complaint, and what you would want to rule out
+- Examples:
+  ENT: NORMAL → "Ears: TMs clear bilaterally, no effusion. Nose: no congestion, no rhinorrhea. Throat: no erythema, no exudates."
+  Skin: NORMAL → "No rash, no petechiae, no bruising."
+  Respiratory: NORMAL → "No cough reported, no wheezing, no shortness of breath."
+  Cardiovascular: NORMAL → "No chest pain, no palpitations."
+- For Physical Exam NORMAL systems, describe a brief normal exam finding:
+  General: NORMAL → "Well-appearing, alert, interactive, in no acute distress."
+  Chest/Lungs: NORMAL → "Clear to auscultation bilaterally, no wheezes, no crackles, no retractions, good air movement."
+  Abdomen: NORMAL → "Soft, non-tender, non-distended, normoactive bowel sounds, no organomegaly."
+  Skin: NORMAL → "Warm, dry, intact. No rashes, no lesions, no petechiae."
+
+For ABNORMAL systems:
+- Use the physician's note as the primary finding
+- Expand the finding into a brief, professional clinical description favoring the MOST COMMON presentation
+- Add only 1-2 closely related pertinent negatives that help narrow the differential — do not be generous with negatives
+- Examples:
+  Skin: ABNORMAL — "pimples on face" → "Skin: multiple inflammatory papules on bilateral cheeks and forehead, consistent with acne vulgaris. No comedones, no cysts."
+  Lungs: ABNORMAL — "wheezing bilaterally" → "Chest/Lungs: bilateral expiratory wheezing throughout, no decreased air entry, no retractions."
+  ENT: ABNORMAL — "red throat" → "Throat: posterior pharyngeal erythema without exudates. Tonsils mildly enlarged, no asymmetry."
+- If the physician later provides clarification (e.g. "it's pustular"), update accordingly
+- Always favor the most common/likely presentation for the described finding
+
+For NOT REVIEWED systems: simply state "Not reviewed" or "Not examined"
+`;
+
 const PROMPTS = {
 
   // ======================== HPI ========================
@@ -217,11 +250,12 @@ Keep clinical and concise — this will be pasted into the encounter note.`,
   // ======================== WELL VISIT NOTE ========================
   wellVisitNote: `You are an expert pediatric physician generating a complete well child visit encounter note.
 ${CORE_RULES}
+${ROS_PE_RULES}
 Sections required:
 Chief Complaint:
 Interval History: (development, growth, behavior, school/activities, diet, sleep, safety since last visit — from transcript if provided)
-Review of Systems: (pertinent only; use physician ROS template if provided under PHYSICIAN TEMPLATES)
-Physical Examination: (use physician exam template if provided; include vital signs and measurements given)
+Review of Systems: (expand each system per ROS/PE rules above — never just write "WNL")
+Physical Examination: (expand each system per ROS/PE rules above — describe specific normal or abnormal findings; include vital signs and measurements given)
 Growth Assessment: (if vitals/measurements provided: comment on growth velocity and percentile trends. For ages ≥2, include BMI percentile and weight classification per AAP 2023 guidelines:
   - Underweight: BMI <5th %ile
   - Healthy Weight: 5th to <85th %ile
@@ -250,26 +284,28 @@ Rules:
   wellVisitShort: `You are an expert pediatric physician.
 Generate a brief well child visit note (SOAP style). Keep concise.
 ${CORE_RULES}
+${ROS_PE_RULES}
 S: Well child visit, brief interval history, parent concerns
-O: Vitals/measurements provided, exam findings (use template if provided). Include growth assessment and BMI classification for ages ≥2.
+O: Vitals/measurements provided. ROS: expand each system with specific pertinent negatives (never just "WNL"). PE: describe specific normal/abnormal findings per system. Include growth assessment and BMI classification for ages ≥2.
 A: Well child, age-appropriate development, growth status, any additional diagnoses
 P: Feeding/nutrition guidance discussed, vaccines, screenings, anticipatory guidance, follow-up`,
 
   // ======================== SICK VISIT NOTE ========================
   sickVisitNote: `You are an expert pediatrician. Generate a concise, professional sick visit note from the provided data.
 ${CORE_RULES}
+${ROS_PE_RULES}
 Include:
 Chief Complaint:
 History of Present Illness: (from transcript/dictation — onset, duration, associated symptoms, pertinent negatives)
-Review of Systems: (from ROS data — document both positive and negative findings for each system reviewed)
-Physical Examination: (from PE data — document normal and abnormal findings; state "not examined" where applicable)
+Review of Systems: (expand each system per ROS/PE rules — NORMAL systems get 1-3 specific pertinent negatives relevant to the chief complaint and differential diagnosis, ABNORMAL systems use the physician's notes expanded into clinical language)
+Physical Examination: (expand each system per ROS/PE rules — NORMAL systems get a brief specific normal exam description, ABNORMAL systems use the physician's notes expanded with the most common presentation in mind. Keep abnormal expansion concise — add at most 1-2 closely related pertinent negatives)
 Assessment and Plan:
 - List diagnoses with ICD-10 codes
 - Treatments and medications prescribed (if mentioned)
 - Follow-up instructions
 - Return precautions
 
-Format as a structured clinical note. Be factual. Only include information explicitly provided. Do not fabricate clinical data.`
+Format as a structured clinical note. Be factual. Do not fabricate clinical data.`
 };
 
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