Bureau of Prisons Health Services Clinical Encounter

| Inmate Name: |

| :--- |

| Date of Birth: |

| Encounter Date: 08/16/2019 07:04 |

Sex:

Provider:

<table border="1"><tr><td>Reg #:</td><td></td></tr><tr><td>Facility:</td><td>NYM</td></tr><tr><td>Unit:</td><td>K01</td></tr></table>

Injury Assessment - Non-work related encounter performed at Health Services.

## SUBJECTIVE:

<table border="1"><tr><td>Date of Injury:</td><td>08/16/2019 06:40</td><td>Date Reported for Treatment:</td><td>08/16/2019 07:05</td></tr><tr><td>Work Related:</td><td>No</td><td>Work Assignment:</td><td>UNASSG</td></tr><tr><td>Pain Location:</td><td></td><td></td><td></td></tr><tr><td>Pain Scale:</td><td>0</td><td></td><td></td></tr><tr><td>Pain Qualities:</td><td>Colicky</td><td></td><td></td></tr><tr><td colspan="4">Where Did Injury Happen(Be specific as to location):11 North</td></tr><tr><td colspan="4">Cause of Injury(Inmate&#x27;s Statement of how injury occurred)&quot;I got caught with a weapon on me&quot;</td></tr><tr><td colspan="4">Symptoms(as reported by inmate)&quot;I have no injury&quot;</td></tr></table>

## OBJECTIVE:

## Pulse:

<table><thead><tr><th>Date</th><th>Time</th><th>Rate Per Minute</th><th>Location</th><th>Rhythm</th><th>Provider</th></tr></thead><tbody><tr><td>08/16/2019</td><td>07:04</td><td>103</td><td>Via Machine</td><td></td><td></td></tr></tbody></table>

## Respirations:

<table><thead><tr><th>Date</th><th>Time</th><th>Rate Per Minute</th><th>Provider</th></tr></thead><tbody><tr><td>08/16/2019</td><td>07:04 NYM</td><td>15</td><td></td></tr></tbody></table>

## Blood Pressure:

<table><thead><tr><th>Date</th><th>Time</th><th>Value</th><th>Location</th><th>Position</th><th>Cuff Size</th><th>Provider</th></tr></thead><tbody><tr><td>08/16/2019</td><td>07:04 NYM</td><td>159/96</td><td></td><td></td><td></td><td></td></tr></tbody></table>



SaO2:


<table><thead><tr><th>Date</th><th>Time</th><th>Value(%)</th><th>Air</th><th>Provider</th></tr></thead><tbody><tr><td>08/16/2019</td><td>07:04 NYM</td><td>96</td><td>Room Air</td><td></td></tr></tbody></table>

## Exam Comments

<table border="1"><tr><td>General: AAOx3. NAD. Calm and noncombative.</td></tr><tr><td>Neck: Supple</td></tr><tr><td>Heart: S1, S2. RRR</td></tr><tr><td>Lungs: CTAB</td></tr><tr><td>Abd: Soft</td></tr><tr><td>EXT: No edema</td></tr><tr><td>Skin: No suspicious lesion or wound</td></tr><tr><td>Neuro: Sensory &amp; motor intact. Gait steady</td></tr></table>

## ASSESSMENT:

Generated 08/16/2019 07:11 by

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Bureau of Prisons - NYM

EFTA00142554

| Inmate Name: | Sex: Race: |
| :--- | :--- |
| Date of Birth: | Facility: NYM |
| Encounter Date: 08/16/2019 07:04 | Unit: K01 |

Encounter for general adult medical exam without abnormal findings, Z0000 - Current

## PLAN:

## Disposition:

Follow-up at Sick Call as Needed

## Other:

IM states he did not sustain any injury and claims no pain or any bodily complaints. He is about to be seen by Psychology soon for psych eval.

<table border="1"><tr><td colspan="5">Patient Education Topics:</td></tr><tr><td>Date Initiated</td><td>Format</td><td>Handout/Topic</td><td>Provider</td><td>Outcome</td></tr><tr><td>08/16/2019</td><td>Counseling</td><td>Access to Care</td><td></td><td>Verbalizes Understanding</td></tr></table>

## Copay Required: No

Cosign Required: Yes

Telephone/Verbal Order: No

| | |

| :--- | :--- |

| Completed by | on 08/16/2019 07:11 |

| Requested to be cosigned by | MD. |

Cosign documentation will be displayed on the following page.

Generated 08/16/2019 07:11 by

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Bureau of Prisons - NYM

EFTA00142555