{ "document_metadata": { "page_number": "1", "document_number": "DOJ-OGR-00024106", "date": "07/28/2019", "document_type": "Clinical Encounter", "has_handwriting": false, "has_stamps": false }, "full_text": "Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/28/2019 06:51 Sex: M Race: WHITE Reg #: 76318-054 Provider: (b)(6); (b)(7)(C) RN Facility: NYM Unit: H01 Nursing - Triage Note encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: (b)(6); (b)(7)(C) RN Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) Subjective: \"I woke up and I had no control over my Right arm for a few minutes it was just doing what it wanted to do\" Pain: No OBJECTIVE: Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/28/2019 06:57 82 (b)(6); (b)(7)(C) RN Respirations: Date Time Rate Per Minute Provider 07/28/2019 06:57 NYM 14 (b)(6); (b)(7)(C) RN Blood Pressure: Date Time Value Location Position Cuff Size Provider 07/28/2019 06:57 NYM 138/80 (b)(6); (b)(7)(C) RN SaO2: Date Time Value(%) Air Provider 07/28/2019 06:57 NYM 98 (b)(6); (b)(7)(C) RN Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 Skin General Yes: Within Normal Limits, Dry, Skin Intact Head General Yes: Symmetry of Motor Function, Atraumatic/Normocephalic No: Facial Asymmetry, Battle's Sign, Raccoon Eyes, Deformity Eyes General Yes: PERRLA, Extraocular Movements Intact Face General Yes: Symmetric Generated 07/28/2019 07:22 by (b)(6); (b)(7)(C) RN Bureau of Prisons - NYM Page 1 of 3", "text_blocks": [ { "type": "printed", "content": "Bureau of Prisons Health Services Clinical Encounter", "position": "header" }, { "type": "printed", "content": "Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/28/2019 06:51 Sex: M Race: WHITE Reg #: 76318-054 Provider: (b)(6); (b)(7)(C) RN Facility: NYM Unit: H01", "position": "top" }, { "type": "printed", "content": "Nursing - Triage Note encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: (b)(6); (b)(7)(C) RN Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) Subjective: \"I woke up and I had no control over my Right arm for a few minutes it was just doing what it wanted to do\" Pain: No", "position": "middle" }, { "type": "printed", "content": "OBJECTIVE: Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/28/2019 06:57 82 (b)(6); (b)(7)(C) RN Respirations: Date Time Rate Per Minute Provider 07/28/2019 06:57 NYM 14 (b)(6); (b)(7)(C) RN Blood Pressure: Date Time Value Location Position Cuff Size Provider 07/28/2019 06:57 NYM 138/80 (b)(6); (b)(7)(C) RN SaO2: Date Time Value(%) Air Provider 07/28/2019 06:57 NYM 98 (b)(6); (b)(7)(C) RN", "position": "middle" }, { "type": "printed", "content": "Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 Skin General Yes: Within Normal Limits, Dry, Skin Intact Head General Yes: Symmetry of Motor Function, Atraumatic/Normocephalic No: Facial Asymmetry, Battle's Sign, Raccoon Eyes, Deformity Eyes General Yes: PERRLA, Extraocular Movements Intact Face General Yes: Symmetric", "position": "middle" }, { "type": "printed", "content": "Generated 07/28/2019 07:22 by (b)(6); (b)(7)(C) RN Bureau of Prisons - NYM Page 1 of 3", "position": "footer" } ], "entities": { "people": [ "JEFFREY EDWARD EPSTEIN" ], "organizations": [ "Bureau of Prisons", "NYM" ], "locations": [], "dates": [ "01/20/1953", "07/28/2019" ], "reference_numbers": [ "76318-054", "DOJ-OGR-00024106" ] }, "additional_notes": "The document contains redacted information marked as (b)(6); (b)(7)(C)." }