{ "document_metadata": { "page_number": "2413", "document_number": "DOJ-OGR-00026089", "date": "07/30/2019", "document_type": "Medical Record", "has_handwriting": false, "has_stamps": false }, "full_text": "Page 2413\nInmate Name: EPSTEIN, JEFFREY EDWARD\nDate of Birth: 01/20/1953 Sex: M Race: WHITE Reg #: 76318-054\nEncounter Date: 07/30/2019 15:58 Provider: (b)(6); (b)(7)(C) MD Facility: NYM Unit: Z01\nExam:\nCranial Nerves (CN) Yes: Within Normal Limits\nMotor System-General Yes: Normal Exam\nMotor System-Strength Yes: Normal Muscular Strength\nASSESSMENT:\nBody mass index (BMI) 27.0-27.9, adult, Z6827 - Current\nConstipation, unspecified, K5900 - Current\nEssential (primary) hypertension, I10 - Current - BY HX.\nHyperlipidemia, unspecified, E785 - Current\nLow back pain, M545 - Current\nNeuralgia and neuritis, unspecified, M792 - Current\nPrediabetes, R7303 - Current\nSleep apnea, G4730 - Current\nPLAN:\nNew Medication Orders:\nRx# Medication Order Date Prescriber Order\nINsulin REG - Human 07/30/2019 15:58 SLIDING SCALE Subcutaneously each morning x 7 day(s) Pill Line Only\nIndication: Prediabetes\nDiscontinued Medication Orders:\nRx# Medication Order Date Prescriber Order\n122148-NYM Insulin Reg (10 ML) 100 UNITS/ML Inj 07/30/2019 15:58 Inject regular insulin subcutaneously per sliding scale: twice daily ***pill line*** for 7 days\nDiscontinue Type: When Pharmacy Processes\nDiscontinue Reason: new order written\nIndication:\nCopay Required: No Cosign Required: No\nTelephone/Verbal Order: No\nCompleted by (b)(6); (b)(7)(C) MD on 07/30/2019 16:12\nGenerated 07/30/2019 16:12 by (b)(6); (b)(7)(C) MD Bureau of Prisons - NYM Page 2 of 2", "text_blocks": [ { "type": "printed", "content": "Page 2413", "position": "header" }, { "type": "printed", "content": "Inmate Name: EPSTEIN, JEFFREY EDWARD\nDate of Birth: 01/20/1953 Sex: M Race: WHITE Reg #: 76318-054\nEncounter Date: 07/30/2019 15:58 Provider: (b)(6); (b)(7)(C) MD Facility: NYM Unit: Z01", "position": "top" }, { "type": "printed", "content": "Exam:\nCranial Nerves (CN) Yes: Within Normal Limits\nMotor System-General Yes: Normal Exam\nMotor System-Strength Yes: Normal Muscular Strength", "position": "middle" }, { "type": "printed", "content": "ASSESSMENT:\nBody mass index (BMI) 27.0-27.9, adult, Z6827 - Current\nConstipation, unspecified, K5900 - Current\nEssential (primary) hypertension, I10 - Current - BY HX.\nHyperlipidemia, unspecified, E785 - Current\nLow back pain, M545 - Current\nNeuralgia and neuritis, unspecified, M792 - Current\nPrediabetes, R7303 - Current\nSleep apnea, G4730 - Current", "position": "middle" }, { "type": "printed", "content": "PLAN:\nNew Medication Orders:\nRx# Medication Order Date Prescriber Order\nINsulin REG - Human 07/30/2019 15:58 SLIDING SCALE Subcutaneously each morning x 7 day(s) Pill Line Only\nIndication: Prediabetes", "position": "middle" }, { "type": "printed", "content": "Discontinued Medication Orders:\nRx# Medication Order Date Prescriber Order\n122148-NYM Insulin Reg (10 ML) 100 UNITS/ML Inj 07/30/2019 15:58 Inject regular insulin subcutaneously per sliding scale: twice daily ***pill line*** for 7 days", "position": "middle" }, { "type": "printed", "content": "Discontinue Type: When Pharmacy Processes\nDiscontinue Reason: new order written\nIndication:\nCopay Required: No Cosign Required: No\nTelephone/Verbal Order: No\nCompleted by (b)(6); (b)(7)(C) MD on 07/30/2019 16:12", "position": "middle" }, { "type": "printed", "content": "Generated 07/30/2019 16:12 by (b)(6); (b)(7)(C) MD Bureau of Prisons - NYM Page 2 of 2", "position": "footer" } ], "entities": { "people": [ "JEFFREY EDWARD EPSTEIN" ], "organizations": [ "Bureau of Prisons" ], "locations": [ "NYM" ], "dates": [ "01/20/1953", "07/30/2019" ], "reference_numbers": [ "76318-054", "122148-NYM", "DOJ-OGR-00026089" ] }, "additional_notes": "The document appears to be a medical record for Jeffrey Epstein, containing his medical assessment and medication orders. Some personal identifiable information is redacted." }