Bureau of Prisons Health Services Clinical Encounter¶
| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M Race: WHITE | Reg #: 76318-054 |
|---|---|---|
| Date of Birth: 01/20/1953 | Facility: NYM | |
| Encounter Date: 07/28/2019 20:25 | Unit: H01 |
Nursing - Follow up encounter performed at Health Services.¶
SUBJECTIVE:¶
| COMPLAINT 1 | Provider: | RN |
| Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) | ||
| Subjective: | Inmate seen for F/U after returning from attorney conference offers no new complaints or worsening S/S stats "My R hand still has pins and needles sometimes" No change in appearance from previous exam. | |
| Pain: | No | |
OBJECTIVE:¶
Pulse:¶
| Date | Time | Rate Per Minute | Location | Rhythm | Provider |
|---|---|---|---|---|---|
| 07/28/2019 | 20:28 | 81 | RN |
Respirations:¶
| Date | Time | Rate Per Minute | Provider |
|---|---|---|---|
| 07/28/2019 | 20:28 NYM | 14 | RN |
| Date | Time | Value | Location | Position | Cuff Size | Provider |
|---|---|---|---|---|---|---|
| 07/28/2019 | 20:28 NYM | 157/91 | RN |
SaO2:¶
| Date | Time | Value(%) | Air |
|---|---|---|---|
| 07/28/2019 | 20:28 NYM | 98 |
Exam:¶
General¶
Affect¶
Yes: Cooperative¶
Appearance¶
Yes: Appears Well, Alert and Oriented x 3¶
Nutrition¶
Yes: Within Normal Limits¶
Skin¶
General¶
Yes: Within Normal Limits, Dry, Skin Intact¶
ASSESSMENT:¶
No Significant Findings/No Apparent Distress¶
PLAN:¶
Disposition:¶
To be Evaluated by Provider¶
Generated 07/28/2019 20:30 by¶
Page 1 of 2¶
RN¶
Bureau of Prisons - NYM¶
EFTA00110361¶
| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M Race: WHITE | Reg #: 76318-054 |
|---|---|---|
| Date of Birth: 01/20/1953 | Facility: NYM | |
| Encounter Date: 07/28/2019 20:25 | Unit: H01 |
Follow-up in 12-24 Hours¶
Patient Education Topics:¶
| Date Initiated Format | Handout/Topic | Provider | Outcome |
|---|---|---|---|
| 07/28/2019 Counseling | Plan of Care | Verbalizes Understanding |
Copay Required: No Cosign Required: Yes¶
Telephone/Verbal Order: No¶
Completed by RN on 07/28/2019 20:30¶
Requested to be cosigned by MD.¶
Cosign documentation will be displayed on the following page.¶
Cosign documentation will be displayed on the following page.¶
Generated 07/28/2019 20:30 by¶
Page 2 of 2¶
RN¶
Bureau of Prisons - NYM¶
EFTA00110362¶
Bureau of Prisons Health Services Cosign/Review¶
Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/28/2019 20:25 Sex: M Provider: RN Reg #: 76318-054 Race: WHITE Facility: NYM¶
Cosigned by MD on 07/28/2019 20:50.¶
Bureau of Prisons - NYM¶