Bureau of Prisons Health Services Clinical Encounter¶
| Inmate Name: |¶
| :--- |¶
| Date of Birth: |¶
| Encounter Date: 08/16/2019 07:04 |¶
Sex:¶
Provider:¶
| Reg #: | |
| Facility: | NYM |
| Unit: | K01 |
Injury Assessment - Non-work related encounter performed at Health Services.¶
SUBJECTIVE:¶
| Date of Injury: | 08/16/2019 06:40 | Date Reported for Treatment: | 08/16/2019 07:05 |
| Work Related: | No | Work Assignment: | UNASSG |
| Pain Location: | |||
| Pain Scale: | 0 | ||
| Pain Qualities: | Colicky | ||
| Where Did Injury Happen(Be specific as to location):11 North | |||
| Cause of Injury(Inmate's Statement of how injury occurred)"I got caught with a weapon on me" | |||
| Symptoms(as reported by inmate)"I have no injury" | |||
OBJECTIVE:¶
Pulse:¶
| Date | Time | Rate Per Minute | Location | Rhythm | Provider |
|---|---|---|---|---|---|
| 08/16/2019 | 07:04 | 103 | Via Machine |
Respirations:¶
| Date | Time | Rate Per Minute | Provider |
|---|---|---|---|
| 08/16/2019 | 07:04 NYM | 15 |
Blood Pressure:¶
| Date | Time | Value | Location | Position | Cuff Size | Provider |
|---|---|---|---|---|---|---|
| 08/16/2019 | 07:04 NYM | 159/96 |
SaO2:¶
| Date | Time | Value(%) | Air | Provider |
|---|---|---|---|---|
| 08/16/2019 | 07:04 NYM | 96 | Room Air |
Exam Comments¶
| General: AAOx3. NAD. Calm and noncombative. |
| Neck: Supple |
| Heart: S1, S2. RRR |
| Lungs: CTAB |
| Abd: Soft |
| EXT: No edema |
| Skin: No suspicious lesion or wound |
| Neuro: Sensory & motor intact. Gait steady |
ASSESSMENT:¶
Generated 08/16/2019 07:11 by¶
Page 1 of 2¶
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.¶
| Patient Education Topics: | ||||
| Date Initiated | Format | Handout/Topic | Provider | Outcome |
| 08/16/2019 | Counseling | Access to Care | Verbalizes Understanding | |
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¶
Page 2 of 2¶
Bureau of Prisons - NYM¶
EFTA00142555¶