{ "document_metadata": { "page_number": "3", "document_number": "DOJ-OGR-00024098", "date": "07/30/2019", "document_type": "Medical Record", "has_handwriting": false, "has_stamps": true }, "full_text": "Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Reg #: 76318-054 Encounter Date: 07/30/2019 11:12 Provider: (b)(6), (b)(7)(C) MD Facility: NYM Unit: Z01 New Medication Orders: Rx# Medication Order Date Prescriber Order Magnesium Hydroxide Susp conc 800 MG/5ML Indication: Constipation, unspecified 07/30/2019 11:12 10 CC Orally - Two Times a Day PRN x 90 day(s) INsulin REG - Human Indication: Prediabetes 07/30/2019 11:12 SLIDING SCALE Subcutaneously - Two Times a Day x 7 day(s) Pill Line Only Renew Medication Orders: Rx# Medication Order Date Prescriber Order 121836-NYM methylPREDnisoLONE 4 MG Tab (21 count Pack) Indication: Neuralgia and neuritis, unspecified 07/30/2019 11:12 Take the tablet by mouth as directed x 6 day(s) New Laboratory Requests: Details Frequency Due Date Priority Lab Tests - Short List-General-CBC w/diff Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short List-General-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic One Time 08/01/2019 00:00 Routine New Radiology Request Orders: Details Frequency End Date Due Date Priority General Radiology-Spine / Cervical-General One Time 08/29/2019 Routine Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH COMPLAINT OF RIGHT ARM NUMBNEESS FOR 2-3 MINUTES 3 DAYS AGO. PLEASE PERFORM C SPINE SERIES Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format Handout/Topic Provider Outcome 07/30/2019 Counseling Access to Care (b)(6), (b)(7)(C) Verbalizes Understanding 07/30/2019 Counseling Plan of Care (b)(6), (b)(7)(C) Verbalizes Understanding Copay Required: No Cosign Required: No Telephone/Verbal Order: No Completed by (b)(6), (b)(7)(C) MD on 07/30/2019 14:05 Generated 07/30/2019 14:05 by (b)(6), (b)(7)(C) MD Bureau of Prisons - NYM Page 3 of 3 DOJ-OGR-00024098", "text_blocks": [ { "type": "printed", "content": "Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Reg #: 76318-054 Encounter Date: 07/30/2019 11:12 Provider: (b)(6), (b)(7)(C) MD Facility: NYM Unit: Z01", "position": "top" }, { "type": "printed", "content": "New Medication Orders: Rx# Medication Order Date Prescriber Order Magnesium Hydroxide Susp conc 800 MG/5ML Indication: Constipation, unspecified 07/30/2019 11:12 10 CC Orally - Two Times a Day PRN x 90 day(s) INsulin REG - Human Indication: Prediabetes 07/30/2019 11:12 SLIDING SCALE Subcutaneously - Two Times a Day x 7 day(s) Pill Line Only", "position": "middle" }, { "type": "printed", "content": "Renew Medication Orders: Rx# Medication Order Date Prescriber Order 121836-NYM methylPREDnisoLONE 4 MG Tab (21 count Pack) Indication: Neuralgia and neuritis, unspecified 07/30/2019 11:12 Take the tablet by mouth as directed x 6 day(s)", "position": "middle" }, { "type": "printed", "content": "New Laboratory Requests: Details Frequency Due Date Priority Lab Tests - Short List-General-CBC w/diff Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short List-General-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic One Time 08/01/2019 00:00 Routine", "position": "middle" }, { "type": "printed", "content": "New Radiology Request Orders: Details Frequency End Date Due Date Priority General Radiology-Spine / Cervical-General One Time 08/29/2019 Routine Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH COMPLAINT OF RIGHT ARM NUMBNEESS FOR 2-3 MINUTES 3 DAYS AGO. PLEASE PERFORM C SPINE SERIES", "position": "middle" }, { "type": "printed", "content": "Disposition: Follow-up at Sick Call as Needed", "position": "middle" }, { "type": "printed", "content": "Patient Education Topics: Date Initiated Format Handout/Topic Provider Outcome 07/30/2019 Counseling Access to Care (b)(6), (b)(7)(C) Verbalizes Understanding 07/30/2019 Counseling Plan of Care (b)(6), (b)(7)(C) Verbalizes Understanding", "position": "middle" }, { "type": "printed", "content": "Copay Required: No Cosign Required: No Telephone/Verbal Order: No Completed by (b)(6), (b)(7)(C) MD on 07/30/2019 14:05", "position": "bottom" }, { "type": "stamp", "content": "See Amendment", "position": "middle" }, { "type": "printed", "content": "Generated 07/30/2019 14:05 by (b)(6), (b)(7)(C) MD Bureau of Prisons - NYM Page 3 of 3 DOJ-OGR-00024098", "position": "bottom" } ], "entities": { "people": [ "JEFFREY EDWARD EPSTEIN", "(b)(6), (b)(7)(C)" ], "organizations": [ "Bureau of Prisons" ], "locations": [ "NYM" ], "dates": [ "01/20/1953", "07/30/2019", "08/01/2019", "08/29/2019" ], "reference_numbers": [ "76318-054", "121836-NYM", "DOJ-OGR-00024098" ] }, "additional_notes": "The document contains redacted information and a 'See Amendment' stamp across the center." }