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: 07/24/2019 13:08 | Unit: H01 |
Mid Level Provider - Follow up Visit encounter performed at Receiving & Discharge.¶
SUBJECTIVE:¶
| COMPLAINT 1 | Provider: |
| Chief Complaint: Other Problem | |
| Subjective: | I still do not want to talk about. But, between you and me. I think my room mate had to do with what happened to me. Do not ask me. I am not going to say anything. |
| Pain: | No |
OBJECTIVE:¶
Temperature:¶
| Date | Time | Fahrenheit | Celsius | Location | Provider |
|---|---|---|---|---|---|
| 07/24/2019 | 13:12 NYM | 97.8 | 36.6 | Oral |
Pulse:¶
| Date | Time | Rate Per Minute | Location | Rhythm | Provider |
| 07/24/2019 | 13:12 | 83 | Via Machine | Regular |
Blood Pressure:¶
| Date | Time | Value | Location | Position | Cuff Size | Provider |
|---|---|---|---|---|---|---|
| 07/24/2019 | 13:12 NYM | 132/89 | Right Arm | Sitting | Adult-regular |
SaO2:¶
| Date | Time | Value(%) | Air | Provider |
|---|---|---|---|---|
| 07/24/2019 | 13:12 NYM | 96 | Room Air |
Exam:¶
General¶
Affect¶
Yes: Cooperative¶
| Appearance |
| Yes: Appears Well, Alert and Oriented x 3 |
| No: Appears Distressed, Appears in Pain |
Exam Comments¶
Follow up evaluation done for inmate Epstein.¶
He does not look in any pain or distress.¶
He still has the erythema around his neck. Central part of this erythema has some abrasion. Patient does not complaint of any respiratory problem or distress. He still does not want to explain how the skin injury on his neck happened. he insinuates that injuries on his neck have to do with his room mate. But does not want to talk about it.¶
ASSESSMENT:¶
Injury, unspecified, T1490 - Current¶
PLAN:¶
Disposition:¶
Generated 07/24/2019 13:24 by¶
Bureau of Prisons - NYM¶
Page 1 of 2¶
CONFIDENTIAL¶
SDNY_00009410 EFTA00123141¶
| Inmate Name: EPSTEIN, JEFFREY EDWARD | Date of Birth: 01/20/1953 | Sex: M | Race: WHITE | Reg #: 76318-054 | Facility: NYM |
|---|---|---|---|---|---|
| Encounter Date: 07/24/2019 13:08 | Provider: | Unit: H01 |
Follow-up at Sick Call as Needed¶
Patient Education Topics:¶
| Date Initiated | Format | Handout/Topic | Provider | Outcome |
|---|---|---|---|---|
| 07/24/2019 | Counseling | Access to Care | Verbalizes Understanding | |
| 07/24/2019 | Counseling | Preventive Health | Verbalizes Understanding |
Copay Required: No Cosign Required: Yes¶
Telephone/Verbal Order: No¶
Completed by on 07/24/2019 13:24¶
Requested to be cosigned by¶
Cosign documentation will be displayed on the following page.¶
Generated 07/24/2019 13:24 by¶
Page 2 of 2¶
Bureau of Prisons - NYM¶
CONFIDENTIAL¶
SDNY_00009411 EFTA00123142¶
Bureau of Prisons Health Services Cosign/Review¶
Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/24/2019 13:08 Sex: M Provider:¶
Reg #: 76318-054 Race: WHITE Facility: NYM¶
Cosigned with New Encounter Note by on 07/24/2019 16:10.¶
Bureau of Prisons - NYM¶
CONFIDENTIAL¶
SDNY_00009412 EFTA00123143¶