EFTA00033804.pdf

Type: pdf
Source set: data-set-8
Extracted text

Bureau of Prisons 
Health Services 
Clinical Encounter 
Inmate Name: EPSTEIN, JEFFREY EDWARD 
Reg #: 
76318-054 
Date of Birth: 
01/20/1953 
Sex: 
M 
Race: WHITE 
Facility: NYM 
Encounter Date: 07/28/2019 20:25 
Provider: 
RN 
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: 
Qata 
Time 
Rate Per Minute 
j•ocation 
Rhythm 
Provider
07/28/2019 20:28 
Respirations: 
Rate 
Time 
07/28/2019 
20:28 NYM 
Blood Pressure: 
Data 
lima 
Value 
07/28/2019 20:28 NYM 
81 
RN 
Rate Per Minute, provider 
14 
RN 
iscation 
position 
Cuff Size 
Provider 
157/91 
RN 
SaO2: 
Dale 
lime 
Valuef%), ALE 
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 07/2812019 20:30 by 
RN 
Provider 
RN 
Bureau of Prisons - NYM 
Page 1 of 2 
CONFIDENTIAL 
SDNY_00009398 
EFTA00033804


Inmate Name: EPSTEIN, JEFFREY EDWARD 
Reg #: 
76318-054 
Date of Birth: 
01/20/1953 
Sex: 
M 
Race: WHITE 
Facility: NYM 
Encounter Date: 07/28/2019 20:25 
Provider: 
RN 
Unit: 
H01 
Follow-up in 12-24 Hours 
Patient Education Topics: 
Pate Initiated format 
Handout/Took
07/28/2019 
Counseling 
Plan of Care 
Copay Required: No 
TelephoneNerbal 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 Required: Yes 
Generated 07/28/2019 20:30 by 
RN 
Bureau of Prisons …
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