mirror-epstein-docs/results/IMAGES009/DOJ-OGR-00024130.json

{
  "document_metadata": {
    "page_number": "5",
    "document_number": "DOJ-OGR-00024130",
    "date": "07/06/2019",
    "document_type": "Medical Encounter Record",
    "has_handwriting": false,
    "has_stamps": false
  },
  "full_text": "Inmate Name: EPSTEIN, JEFFREY EDWARD\nDate of Birth: 01/20/1953\nEncounter Date: 07/06/2019 21:38\nSex: M\nProvider: (b)(6) (b)(7)(C) PA-C\nReg #: 76318-054\nRace: WHITE\nFacility: NYM\n\nHealth Problems Newly Identified During This Encounter:\nHealth Problem\n\nMedication Reconciliation.\nThe patient's known medication list including OTC items was compiled and compared to new and changed BOP orders.\n\nReconciled Medications:\nSource Action Type Rx# Medication Order Detail\nOTC No known OTCs\n\nNew Laboratory Requests:\nDetails Frequency Due Date Priority\nLab Tests-H-Hemoglobin A1C One Time 08/05/2019 00:00 Routine\nLab Tests-C-CBC w/diff\nLab Tests-L-Lipid Profile\nLab Tests-C-Comprehensive Metabolic Profile (CMP)\nLab Tests-U-Urinalysis w/Reflex to Microscopic\nAdditional Information:\n66 y/o male, elevated BP\nLabs requested to be reviewed by: (b)(6) (b)(7)(C) MD\n\nNew Non-Medication Orders:\nOrder Frequency Duration Details Ordered By\nEKG One Time 66 y/o male (b)(6) (b)(7)(C) PA-C\nOrder Date: 07/06/2019\nFecal Occult Blood One Time 3 different stools\nOrder Date: 07/06/2019\n\nSchedule:\nActivity Date Scheduled Scheduled Provider\nVision Screen 07/06/2019 00:00 Optometrist\n66 y/o male\nPPD Reading 07/08/2019 00:00 Nurse\nFollow-up 07/09/2019 00:00 Mid-Level Provider\nBP check\n\nOther:\nBP noticed to be elevated.\nIM denies Hx of HTN or any significant chronic medical conditions.\nHe is currently asymptomatic and denies any bodily complaints at this time.\nWill recheck BP in 2-3 days.\n\nDisposition:\nFollow-up at Sick Call as Needed\nTo be Evaluated by Provider\n\nInstructed inmate how to obtain medical, dental, and mental health care.\n\nCopay Required:No Cosign Required: Yes\nTelephone/Verbal Order: No\n\nGenerated 07/06/2019 21:56 by (b)(6) PA-C Bureau of Prisons - NYM Page 5 of 6",
  "text_blocks": [
    {
      "type": "printed",
      "content": "Inmate Name: EPSTEIN, JEFFREY EDWARD\nDate of Birth: 01/20/1953\nEncounter Date: 07/06/2019 21:38\nSex: M\nProvider: (b)(6) (b)(7)(C) PA-C\nReg #: 76318-054\nRace: WHITE\nFacility: NYM",
      "position": "top"
    },
    {
      "type": "printed",
      "content": "Health Problems Newly Identified During This Encounter:\nHealth Problem",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Medication Reconciliation.\nThe patient's known medication list including OTC items was compiled and compared to new and changed BOP orders.",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Reconciled Medications:\nSource Action Type Rx# Medication Order Detail\nOTC No known OTCs",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "New Laboratory Requests:\nDetails Frequency Due Date Priority\nLab Tests-H-Hemoglobin A1C One Time 08/05/2019 00:00 Routine\nLab Tests-C-CBC w/diff\nLab Tests-L-Lipid Profile\nLab Tests-C-Comprehensive Metabolic Profile (CMP)\nLab Tests-U-Urinalysis w/Reflex to Microscopic\nAdditional Information:\n66 y/o male, elevated BP\nLabs requested to be reviewed by: (b)(6) (b)(7)(C) MD",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "New Non-Medication Orders:\nOrder Frequency Duration Details Ordered By\nEKG One Time 66 y/o male (b)(6) (b)(7)(C) PA-C\nOrder Date: 07/06/2019\nFecal Occult Blood One Time 3 different stools\nOrder Date: 07/06/2019",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Schedule:\nActivity Date Scheduled Scheduled Provider\nVision Screen 07/06/2019 00:00 Optometrist\n66 y/o male\nPPD Reading 07/08/2019 00:00 Nurse\nFollow-up 07/09/2019 00:00 Mid-Level Provider\nBP check",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Other:\nBP noticed to be elevated.\nIM denies Hx of HTN or any significant chronic medical conditions.\nHe is currently asymptomatic and denies any bodily complaints at this time.\nWill recheck BP in 2-3 days.",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Disposition:\nFollow-up at Sick Call as Needed\nTo be Evaluated by Provider",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Instructed inmate how to obtain medical, dental, and mental health care.",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Copay Required:No Cosign Required: Yes\nTelephone/Verbal Order: No",
      "position": "bottom"
    },
    {
      "type": "printed",
      "content": "Generated 07/06/2019 21:56 by (b)(6) PA-C Bureau of Prisons - NYM Page 5 of 6",
      "position": "bottom"
    }
  ],
  "entities": {
    "people": [
      "JEFFREY EDWARD EPSTEIN"
    ],
    "organizations": [
      "Bureau of Prisons"
    ],
    "locations": [
      "NYM"
    ],
    "dates": [
      "01/20/1953",
      "07/06/2019",
      "08/05/2019",
      "07/08/2019",
      "07/09/2019"
    ],
    "reference_numbers": [
      "76318-054",
      "DOJ-OGR-00024130"
    ]
  },
  "additional_notes": "The document appears to be a medical encounter record for inmate Jeffrey Edward Epstein. It contains various sections including medication reconciliation, laboratory requests, non-medication orders, and disposition. Some personal identifiable information is redacted."
}