EFTA00142554.pdf

Bureau of Prisons Health Services Clinical Encounter Inmate Name: Reg #: Date of Birth: Sex: U Race: Facility: NYM Encounter Date: 08/16/2019 07:04 Provider: Unit: K01 Injury Assessment - Non-work related encounter performed at Health Services. SUBJECTIVE: INJURY 1 Provider: 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: Dale 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(%1 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 08116/2019 07: t t by Bureau of Prisons - NYM Page 1 of 2 EFTA00142554 Inmate Name: Reg #: Date of Birth: Sex: Race: Facility: NYM Encounter Date: 08/16/2019 07:04 Provider: 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/Topir Provider Outcome 08/16/2019 Counseling Access to Care Verbalizes Understanding Copay Required:No Cosign Required: Yes TelephoneNerbal 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 08116/2019 07:11 by Bureau of Prisons - NYM Page 2 of 2 EFTA00142555