EFTA00073831.pdf
Extracted Text (OCR)
2019-05665
Item 9, 13, 17 (partial), 18 (partial)
EFTA00073831
Bureau of Prisons
Health Services
Clinical Encounter
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 08/10/2019 07:25
Provider
Reg #:
76318-054
M
Race: WHITE
Facility: NYM
RN
Unit:
Z04
Emergency Code Resuscitation Event encounter performed at Special Housing Unit.
SUBJECTIVE:
Emergency Note Provider:
RN
Team Members:
Provider
Bole
RN
Team/Code Leader
Code Events:
Type
Value
Date
CPR
Compressions
08/10/2019 06:35
EKG/Monitor
Lifepak
08/10/2019 06:39
No shock advised
CPR
Compressions
08/10/2019 06:40
Oxygen
15 L
08/10/2019 06:47
IV Access
Peripheral IV
08/10/2019 06:48
18 g Left AC
Page 001 of 148
Airway
Endotracheal Tube
08/10/2019 07:08
Withheld pursuant to exemption
ET Tube 7.5 24CM to L Lip line Placed by Paramedics
Medications
Epinephrine 1mg IV
(b)(6) (b)(7)(A); (b)(7)(C)
08/10/2019 07:10
Epinephrine 3 doses and Sodium bicarb 2 doses administered by paramedics
CPR
Compressions of the Freedom of Information and Privacy Act,
cro/10/2019 07:11
Medications
Sodium Bicarbonate 1 mEaikg IV
08/10/2019 07:11
IV Fluids
Normal Saline 0.9% 1000 ml
08/10/2019 07:12
Medications
Epinephrine 1mg IV
08/10/2019 07:13
CPR
Compressions
08/10/2019 07:14
Medications
Sodium Bicarbonate 1 mEaikg IV
08/10/2019 07:14
Medications
Epinephrine 1mg IV
08/10/2019 07:16
CPR
Compressions
08/10/2019 07:17
Comments:
Responded to a body alarm at 0635 for medical emergency on 9S. Upon arrival Inmate was received on the floor of his
cell unresponsive with CPR in progress by correctional officers, Inmate was Cold, with circumferential Bruising around the
neck and posterior mottling, Pupils Fixed and dilated, No Palpable pulses, Call place for EMS, CPR Continued, AED
Placed No shock advised, CPR Continued. inmate transported to HSU treatment room with CPR in progress, 18g hep lock
to L AC, O2 15 Lt ViA BVM. Pulse Check NO SHOCK advised. EMS and Paramedics arrived 0656. Placed on cardiac
monitor asystole Resumed CPR. Inmate was intubated by Medics. 3 Rounds of Epinephrine administered. Pulse Check
asystole, Inmate was transported to Local ER with CPR in progress.
OBJECTIVE:
Exam:
General
Appearance
Yes: Unconscious
Generated 08 10 2019 08.10 by
RN
Bureau of Prisons - NYM
Page 1 of 2
EFTA00073832
Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Facility: NYM
Encounter Date: 08/10/2019 07:25
Provider:
RN
Unit:
Z04
Exam:
ASSESSMENT:
Cardiac Arrest
PLAN:
New Consultation Requests:
Consultation/Procedure
Target Date Scheduled Target Date Priority
Translator
Language
Emergency Room
08/10/2019
08/10/2019
Emergent
No
Subtype:
AMBULANCE
Reason for Request:
Cardiac arrest with CPR in progress
Copay Required: No
Cosign Required: Yes
TelephoneNerbal Order: No
Completed by
RN on 08/10/2019 08:10
Requested to be cosigned by
Cosign documentation will be displayed on the following page.
Page 002 of 148
Withheld pursuant to exemption
(b)(6) : (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 08/1012019 08:10 by
RN
Bureau of Prisons NYM
Page 2 of 2
EFTA00073833
Bureau of Prisons
Health Services
Cosign/Review
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 08/10/2019 07:25
Provider:
RN
Facility:
NYM
Cosigned by
on 08/12/2019 08:09.
Page 003 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Bureau of Prisons NYM
EFTA00073834
Bureau of Prisons
Health Services
Clinical Encounter
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/30/2019 15:58
Provider
M
Race: WHITE
Reg #:
76318-054
Facility: NYM
Unit:
Z01
Chronic Care Chronic Care Clinic encounter performed at Health Services.
SUBJECTIVE:
COMPLAINT 1
Provider:
Chief Complaint: Other Problem
Subjective:
PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION.
PATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE
ALSO REPORTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO.
STATES THE NUMBNESS WENT AWAY ON ITS OWN. BUT WAS VERY CONCERNING.
HE DENIES RIGHT SIDED WEAKNESS. DIPLOPIA. FACIAL DROOP. DIFFICULTY
SPEAKING OR SWALLOWING.
HE REPORTS NOCTURIA OF ABOUT 5 TIMES.. HE DENIES DYSURIA.
HE REPORTS H OF KIDNEY STONES. HX OF HTN FOR WHICH HE WAS TAKING
TOPROL.
HE AHS A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEEKS
ISNCE HE HASB EEN HERE SINCE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I
INFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVEN TO
HIM TONIGHT..
HE REPORT OTHER NON-MEDICAL ISSUE
rage uu4 of 148
STATES HE FEELS OTHERWISE FINE.
Pain:
Not Applicable
Withheld pursuant to exemption
Seen for clinic(s): Pulmonary/Respiratory. Orthopedic,Rheumatology, Endocrine/Lipid
(b)(6), (b)(7)(C)
OBJECTIVE:
of the Freedom of Information and Privacy Act
Exam:
General
Affect
Yes: Cooperative
Appearance
Yes: Appears Well. Alert and Oriented x 3
No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic,
Disheveled. Unkempt. Acutely III
Nutrition
No: Appears Obese
Pulmonary
Auscultation
Yes: Clear to Auscultation
Cardiovascular
Auscultation
Yes: Regular Rate and Rhythm (RRR), Normal SI and S2
No: MITG
Musculoskeletal
Tibia / Fibula
No: Edema
Neurologic
Generated 07 302019 16.12 by
Bureau of Prisons - NYM
Page 1 of 2
EFTA00073835
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Encounter Date: 07/30/2019 15:58
Sex:
Provider
M
Race: WHITE
Reg #:
76318-054
Facility: NYM
Unit:
701
Exam:
Cranial Nerves (CN)
Yes: Within Normal Limits
Motor System-General
Yes: Normal Exam
Motor System-Strength
Yes: Normal Muscular Strength
ASSESSMENT:
Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current
Constipation, unspecified. K5900 - Current
Essential (primary) hypertension, 110 - Current - BY HX.
Hyperlipidemia, unspecified, E785 - Current
Low back pain, M545 - Current
Neuralgia and neuritis, unspecified, M792 - Current
Prediabetes, R7303 - Current
Sleep apnea, G4730 - Current
PLAN:
Page 005 of 148
New Medication Orders:
Rxtl
Medication
INsulin REG - Human
Withheld pursuant to exemption
Order Date
(b)(8); (b)(dXM10;/0)(g)11%)58
of the Freedom of Information and Privacy Act
Indication: Prediabetes
Discontinued Medication Orders:
Rx#
Medication
Order Date
122148-NYM
Insulin Reg (10 ML) 100 UNITSML lnj
07/30/2019 15:58
Discontinue Type:
When Pharmacy Processes
Discontinue Reason: new order written
Indication:
Copay Required:No
Telephone/Verbal Order: No
Completed by
Cosign Required: No
on 07/30/2019 16:12
Prescriber Order
SLIDING SCALE
Subcutaneously each morning x
7 day(s) Pill Line Only
Prescriber Order
Inject regular insulin
subcutaneously per sliding scale:
twice daily —*pill line"' for 7
days
Generated 0730:2019 16:12 by
Bureau of Prisons - NYM
Page 2 of 2
EFTA00073836
Bureau of Prisons
Health Services
Clinical Encounter
Inmate Name: EPSTEIN. JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Encounter Date: 07/30/2019 11:12
Provider:
Reg #:
76318-054
Facility: NYM
Unit:
Z01
Chronic Care - Chronic Care Clinic encounter performed at Health Services.
SUBJECTIVE:
COMPLAINT 1
Provider:
Chief Complaint: Other Problem
Subjective:
PATIENT
PATIE
ALS
STAT
HE DEN
SPEAKING
HE REPORT
HE REPORTS
TOPROL.
HE AHS A HX OF SLEEP
ISNCE HE HASB EEN
INFORME DHIM THAT WE
HIM TONIGHT..
HE REPORT OTHER NON-ME
STATES HE FEELS OTHERWISE PIN
Pain:
Not Applicable
Withheld
REFERRED BY THE WARDEN FOR EVALUATION.
RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE
S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO.
BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING.
SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY
OWING.
IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA.
NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING
AND STATED HE HAS NOT SLEPT FOR 3 WEEKS
E HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I
HIS CPAP MACHINE AND IT WILL BE GIVEN TO
Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology'
(b)(6) (b)(
OBJECTIVE:
Pulse:
Dale
07/30/2019
07/30/2019
07/30/2019
Respirations:
pate
Time
07/30/2019
09:30 NYM
€W8 of 148
o exemption
of the Freedom of Information
lime
Rate Per Minute
13:02
94
09:40
88
09:30
87
Location
Via Machine
Via Machine
Rate Per Minute Provider
Blood Pressure:
Date
limes
Value
Location
07/30/2019 13:02 NYM 114/84
Left Arm
07/30/2019 09:40 NYM 125/60
Right Arm
07/30/2019 09:30 NYM 108/86
Left Arm
SaO2:
Dale
lime
Value(%) Air
07/30/2019
09:30 NYM
98 Room Air
Weight:
Date
Time
Lbs
12
Respiratory
XC)
Position
Standing
Standing
Sitting
Provider
eaudouin, Robert MD
&Quin.
Robert MD
Robert MD
Cuff Size
Provider
Provider
Kg Waist Circum. Provider
Generated 07/30/2019 14:05 by
Bureau of Prisons - NYM
Page 1 of 3
EFTA00073837
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/30/2019 11:12
Provider:
Reg #:
76318-054
M
Race: WHITE
Facility: NYM
Unit:
Z01
Date
Time
Lba
Kg Waist Circum, Provider
07/30/2019
09:30 NYM
194.2
88.1
Exam:
General
Affect
Yes: Cooperative
Appearance
Yes: Appears Well, Alert and Oriented x 3
No: Appears Distr
ed. Dyspneic. Appears in Pain. Writhing in Pain, Pale. Pallor. Cyanotic, Diaphoretic.
Disheveled, Unk
cutely III
Nutrition
No: Appears O
Pulmonary
Auscultation
Yes: Clear to Auscultation
Cardiovascular
Auscultation
Yes: Regular Rate and Rhythm (RRR
1 and S2
No: Mil(G
Musculoskeletal
Tibia / Fibula
No: Edema
Neurologic
Cranial Nerves (CN)
of the Freedom of Information
Yes: Within Normal Limits
Motor System-General
Yes: Normal Exam
Motor System-Strength
Yes: Normal Muscular Strength
ASSESSMENT:
Withheld
e 007 of 148
exemption
(b)(8). (b)(7)
(
)(C)
Body mass index (BMI) 27.0-27.9. adult. Z6827 - Current
Constipation. unspecified, K5900 - Current
Essential (primary) hypertension, 110 - Current - BY HX.
Hyperlipidemia, unspecified, E785 - Current
Low back pain, M545 - Current
Neuralgia and neuritis, unspecified, M792 - Current
Prediabeles, R7303 - Current
Sleep apnea, G4730 - Current
PLAN:
New Medication Orders:
R x#
Medication
Order Date
Prescriber Order
Generated 07/30.2019 14.05 by
Bureau of Prisons - NYM
Page 2 of 3
EFTA00073838
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/30/2019 11:12
Provider
Reg #:
76318-054
M
Race: WHITE
Facility: NYM
Unit:
Z01
New Medication Orders:
Rx#
Medication
Magnesium Hydroxide Susp conc 800
MG15ML
Indication: Constipation. unspecified
INsulin REG - Human
Indication: Prediabetes
Renew Medication Orders:
Rxff
Medication
Order Date
Prescriber Order
121836-NYM
methylP
ne 4 MG Tab ( 21 count
07/30/2019 11:12
Take the tablet by mouth as
Pack)
directed x 6 day(s)
Indication:
a and neuritis, unspecified
New Laboratory Requests:
Details
Frequency
Due Date
Priority
Lab Tests - Short List-General-CBC w diff
ane
Time
08/01/2019 00:00
Routine
Lab Tests-P-PSA, Total
Lab Tests-U-Uric Acid
Lab Tests - Short List-General-Comprehensiv
Metabolic Profile (CMP)
Lab Tests-U-Urinalysis w/Reflex to Microscopic
New Radiology Request Orders:
Order Date
07/30/2019 11:12
07/30/2019 11:12
Prescriber Order
10 CC Orally - Two Times a
Day PRN x 90 day(s)
SLIDING SCALE
Subcutaneously - Two Times a
Day x 7 day(s) Pill Line Only
008 of 148
Withheld
e emption
Details
Frequency
Due Date
General Radiology-Spine / Cervical-
One Ti(ix)(6); (b)(
)(C)
08/29/2019
General
Specific reason(s) for request (ttfififtSiffigraei6 InfRnalje
66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI
PLEASE PERFORM C SPINE SERIES
Disposition:
Follow-up at Sick Call as Needed
Patient Education Topics:
Date initiated Format
07/30/2019
Counseling
Handout/Topic
Access to Care
07/30/2019
Counseling
Plan of Care
Copay Required:No
Cosign Required: No
Telephone, Verbal Order: No
Completed by
on 07/30/2019 14:05
Priority
Routine
2-3 MINUTES 3 DAYS AGO.
Pipit l
Outcome
Beaudo
Robert
Verbalizes
Understanding
Verbalizes
Understanding
Generated 07 30'2019 14:05 by
Bureau of Prisons - NYM
Page 3 of 3
EFTA00073839
Bureau of Prisons
Health Services
Clinical Encounter
Inmate Name: EPSTEIN. JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Facility: NYM
Encounter Date: 07/30/2019 11:12
Provider:
Unit:
Z01
Chronic Care - Chronic Care Clinic encounter performed at Health Services.
SUBJECTIVE:
COMPLAINT 1
Provider:
Chief Complaint: Other Problem
Subjective:
PATIENT
REFERRED BY THE WARDEN FOR EVALUATION.
PATIE
RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE
ALS
E
S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO.
STAT
BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING.
HE DEN
HI SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY
SPEAKING
OWING.
HE REPORT
IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA.
HE REPORTS
'NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING
TOPROL.
HE AHS A HX OF SLEEP
AND STATED HE HAS NOT SLEPT FOR 3 WEEKS
ISNCE HE HASB EEN
CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I
INFORME DHIM THAT WE
EBED HIS CPAP MACHINE AND IT WILL BE GIVEN TO
HIM TONIGHT..
HE REPORT OTHER NON-ME
STATES HE FEELS OTHERWISE PIN
Pain:
Not Applicable
Withhelddi
o exemption
Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology,
Respiratory
(b)(6) (b)(
)(C)
OBJECTIVE:
Pulse:
Date
Time
Rate Per Minute
Location
07/30/2019 13:02
94
07/30/2019 09:40
88
Via Machine
07/30/2019 09:30
87
Via Machine
of the Freedom of Information
Respirations:
Date
lime
Rate Per Minute Provider
07/30/2019
09:30 NYM
12
Blood Pressure:
Data
07/30/2019
07/30/2019
07/30/2019
SaO2:
Time
Value
Location
Position
13:02 NYM 114/84
Left Arm
Standing
09:40 NYM 125/60
Right Arm
Standing
09:30 NYM 108/86
Left Arm
Sitting
Provider
eaudouin, Robed MD
e ouin.
Robed MD
Robert MD
Cuff Size
Provider
Date
Time
Value(%) Alt
Provider
07/30/2019
09:30 NYM
98 Room Air
Weight:
Pale
Time
Lin
Kg Waist Circum. Provider
Generated 07/3012019 14:05 by
Bureau of Prisons - NYM
Page 1 of 3
EFTA00073840
Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/30/2019 11:12
Provider:
M
Race: WHITE
Reg #:
76318-054
Facility: NYM
Unit:
Z01
Dale
Time
07/30/2019
09:30 NYM
194.2
88.1
LIM
Kg Waist Circum Provider
Exam:
General
Affect
Yes: Cooperative
Appearance
Yes: Appears Well, Alert and Oriented x 3
No: Appears Distr
ed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic,
Disheveled, Unk
cutely III
Nutrition
No: Appears O
Pulmonary
Auscultation
Yes: Clear to Auscultation
Cardiovascular
Auscultation
Yes: Regular Rate and Rhythm (RRR
No: M•IG
Musculoskeletal
Tibia / Fibula
No: Edema
Neurologic
Cranial Nerves (CN)
of the Freedom of Information
Yes: Within Normal Limits
Motor System-General
Yes: Normal Exam
Motor System-Strength
Yes: Normal Muscular Strength
ASSESSMENT:
1 and S2
e 010 of 148
le
exemption
(b)(6): (b)( )
• (•
)(C)
Body mass index (BMI) 27.0.27.9, adult, Z6827 - Current
Constipation, unspecified, K5900 - Current
Essential (primary) hypertension, 110 - Current - BY HX.
Hyperlipidemia, unspecified, E785 - Current
Low back pain, M545 - Current
Neuralgia and neuritis, unspecified, M792 - Current
Prediabetes, R7303 - Current
Sleep apnea, G4730 - Current
PLAN:
New Medication Orders:
Exit
Medication
Order Date
Prescriber Order
Generated 07/3012019 14:05 by
Bureau of Prisons - NYM
Page 2 of 3
EFTA00073841
Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Facility: NYM
Encounter Date: 07/30/2019 11:12
Provider:
Unit:
Z01
New Medication Orders:
BLit(
Medication
Order Date
Prescriber Order
Magnesium Hydroxide Susp conc 800
07/30/2019 11:12
10 CC Orally - Two Times a
MG/5ML
Day PRN x 90 day(s)
Indication: Constipation, unspecified
INsulin REG - Human
07/30/2019 11:12
SLIDING SCALE
Subcutaneously
Two Times a
Day x 7 day(s) Pill Line Only
Indication: Prediabetes
Renew Medication Orders:
&ft
Medication
Order Date
Prescriber Order
121836-NYM
methylP
ne 4 MG Tab ( 21 count
07/30/2019 11:12
Take the tablet by mouth as
Pack)
directed x 6 day(s)
Indication:
a and neuritis, unspecified
New Laboratory Requests:
Details
Frequency
Lab Tests - Short List-General-CBC w diff
ane
Time
Lab Tests-P-PSA, Total
Lab Tests-U-Uric Acid
Lab Tests - Short List-General-Comprehensiv
Metabolic Profile (CMP)
Lab Tests-U-Urinalysis w/Reflex to Microscopic
New Radiology Request Orders:
Details
General Radiology-Spine / Cervical-
General
Specific reason(s) for request ft 8ffirfffeftliekilfliRMISP
66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI
PLEASE PERFORM C SPINE SERIES
Disposition:
Follow-up at Sick Call as Needed
Patient Education Topics:
Date Initiated Format
Handout/Topic
Prov
Outcome
07/30/2019
Counseling
Access to Care
Beaudo
Robert
Verbalizes
Understanding
07/30/2019
Counseling
Plan of Care
Verbalizes
Understanding
Frequency
One Ti0b)(6); (b
e 011 of 148
Due Date
08/01/2019 00:00
Routine
Priority
e emption
Due Date
)(C)
08/29/2019
Priority
Routine
2-3 MINUTES 3 DAYS AGO.
Copay Required:No
Cosign Required: No
TelephoneNerbal Order: No
Completed by
on 07/30/2019 14:05
Generated 07130/2019 14:05 by
Bureau of Prisons - NYM
Page 3 of 3
EFTA00073842
Bureau of Prisons
Health Services
See Amendment
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/30/2019 15:58
Facility:
NYM
Amendment made to this note by
on 07/30/2019 16:12.
Page 012 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A): (b)(7)(C)
of the Freedom of Information and Privacy Act
Bureau of Prisons - NYM
EFTA00073843
Bureau of Prisons
Health Services
Clinical Encounter
Inmate Name:
EPSTEIN. JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/28/2019 20:25
Provider
Reg #:
76318-054
M
Race: WHITE
Facility: NYM
RN
Unit:
H01
Nursing - Follow up encounter performed at Health Services.
SUBJECTIVE:
COMPLAINT 1
Provider:
RN
Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies)
Subjective:
Inmate seen for F/U after returning from attorney conference offers no new complaints or
worsening S/S stats My, hand still has pins and needles sometimes" No change in
appearance from previous exam.
Pain:
No
OBJECTIVE:
Pulse:
Date
Time
07/28/2019 20:28
Respirations:
Date
07/28/2019
Blood Pressure:
Date
Time
07/28/2019 20:28 NYM
SaO2:
Date
Time
yatue(%) Air
07/28/2019
20:28 NYM
98
Rate Per Minute
Location
Rhythm
Provider
Time
20:28 NYM
Value
157/91
Exam:
General
Affect
Yes: Cooperative
Appearance
Yes: Appears Well, Alert and Oriented x 3
Nutrition
Yes: Within Normal Limits
Skin
General
Yes: Within Normal Limits. Dry. Skin Intact
ASSESSMENT:
No Significant Findings/No Apparent Distress
PLAN:
Disposition:
To be Evaluated by Provider
Generated 0712812019 20:30 by
81
Rate Per Minute Provider
14
Withheld pursuant to exemption
Location
(b)WPO:jR9)(A): (b)Filk-PiZe
of the Freedom of Information and Privacy Act
Provider
Provider
RN
RN
RN
RN
Bureau of Prisons - NYM
Page 1 of 2
EFTA00073844
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/28/2019 20:25
Provider
Reg #:
76318-054
M
Race: WHITE
Facility: NYM
RN
Unit:
H01
Follow-up in 12-24 Hours
Patient Education Topics:
ttate_lnitiated Formal
Handout/Topic
07/28/2019
Counseling
Plan of Care
Copay Required:No
Cosign Required: Yes
Telephone/Verbal Order: No
Completed by
RN on 07/28/2019 20:30
Requested to be cosigned by
Cosign documentation will be displayed on the following page.
Page 014 of 148
Withheld pursuant to exemption
(b)(6) (b)(7)(A): (b)(7)(C)
of the Freedom of Information and Privacy Act
Provider
Outcome
Verbalizes
Understanding
Generated 07/28/2019 20:30 by
RN
Bureau of Prisons - NYM
Page 2 of 2
EFTA00073845
Bureau of Prisons
Health Services
Cosign/Review
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/28/2019 20:25
Provider:
RN
Facility:
NYM
Cosigned by
on 07/28/2019 20:50.
Page 015 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Bureau of Prisons NYM
EFTA00073846
Bureau of Prisons
Health Services
Clinical Encounter
Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Facility: NYM
Encounter Date: 07/28/2019 06:51
Provider:
RN
Unit:
H01
Nursing - Triage Note encounter performed at Health Services.
SUBJECTIVE:
COMPLAINT 1
Provider:
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:
Dale
Time
07/28/2019 06:57
Rate Per Minute
location
Rhythm
Provider
82
Respirations:
DAM
lime
Rate Per Minute Pr vider
07/28/2019
06:57 NYM
14
Blood Pressure:
Dale
Time
Value
LocationWithhe0cPtlif8iint to extaidni(gize
07/28/2019 06:57 NYM 138/80
(b)(6) : (b)(7)(A): (b)(7)(C)
SaO2:
of the Freedom of Information and Privacy Act
DAM
Time
ValuerY41 Alt
Provider
07/28/2019
06:57 NYM
98
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, AtraumaticlNormocephalic
No: Facial Asymmetry, Battle's Sign, Raccoon Eyes, Deformity
Eyes
General
Yes:
, Extraocular Movements Intact
Face
General
Yes: Symmetric
Generated 07128;2019 07:22 by■
RN
Provider
RN
RN
RN
Bureau of Prisons - NYM
Page 1 of 3
EFTA00073847
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/28/2019 06:51
Provider
Reg #:
76318-054
M
Race: WHITE
Facility: NYM
RN
Unit:
H01
Exam:
No: Ecchymosis, Numbness, Swelling. Periorbital Edema
Neck
General
Yes: Abrasion(s)
Pulmonary
Observation/Inspection
Yes: Within Normal Limits
No: Respiratory Distress, Tachypnea, Hyperventilation
Cardiovascular
Observation
Yes: Normal Rate
Musculoskeletal
Shoulder
Yes: Full Range of Motion
Symmetric,
No: Swelling I, Inflammation'
Humerus
Yes: Within Normal Limits,
Elbow
Yes: Normal Exam I, Full Range of Motion', Nikkfie0tnicibrlifeilpation I
Radius / Ulna
Withhdd pursuant to exemption
Yes: Normal Exam
Full Range of Motion I
Wrist/Hand/Fingers
(b)(6); (b)(7)(A) ; (b)(7)(C)
Yes: Full Range of Motion RoNtitio*HefRAAtigoog•Awitleiviic9 Act
No: Inflammation I. Ecchymosis
Erythema'. Tenderness
Laceration(s) I, Abrasion(s) I,
Contusion(s)
I
ROS Comments
Received inmate AAOX3 in no acute distress, speaking in full sentenced ambulating independently C/O Right arm
numbness after waking up from "sleeping on my side" that has since subsided. inmate interviewed in psyc obs through
the slot. ViS noted WNL. RR even and unlabored, no neurological deficits noted, no facial droop slurred speech or
dysphagia. Inmate with Full ROM to all extremities with 4/4 strength bilaterally• slight swelling noted to right phalanges
when compared to left, no edema, erythema or ecchymosis noted. Denies an
ain numbness or tingling at this time.
Denies any Chest pain, Headache, Dizziness, SOB or Blurred vision. Eyes
. MD on Call notified. Re-evaluate
this evening or sooner if S/S persist.
ASSESSMENT:
Alteration in comfort
PLAN:
Disposition:
Follow-up at Sick Call as Needed
Notify Medical Duty Officer
Patient Education Topics:
Pate Initiated Format
Handout/Topic
Provider
Outcome
07/28/2019
Counseling
Plan of Care
Verbalizes
Understanding
Generated 07/28/2019 07:22 by
RN
Bureau of Prisons - NYM
Page 2 of 3
EFTA00073848
Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/28/2019 06:51
Provider:
Reg #:
76318-054
M
Race: WHITE
Facility: NYM
RN
Unit:
H01
Date Initiated Format
Randoutagpic
Provider
Outcome
Copay Required:No
Cosign Required: Yes
Telephone/Verbal Order: No
Completed by
RN on 07/28/2019 07:22
Requested to be cosigned by
Cosign documentation will be displayed on the following page.
Page 018 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07/28/2019 07:22 by
RN
Bureau of Prisons - NYM
Page 3 of 3
EFTA00073849
Bureau of Prisons
Health Services
Cosign/Review
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/28/2019 06:51
Provider:
RN
Facility:
NYM
Cosigned by
on 07/28/2019 20:51.
Page 019 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Bureau of Prisons NYM
EFTA00073850
Bureau of Prisons
Health Services
Clinical Encounter - Administrative Note
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Note Date:
07/26/2019 08:57
Provider:
Reg #:
76318-054
Parr WHITE
Facility:
NYM
Unit:
H01
Cosign Note - Clinical Encounter Cosign encounter performed at Health Services.
Administrative Notes:
ADMINISTRATIVE NOTE 1
Provider:
THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM
2 NIGHTS AGO.
New Medication Orders:
That
Medication
Order Date
Prescriber Order
Docusate Sodium Capsule
07/26/2019 08:57
TAKE ONE 100 MG CAP Orally
- Two Times a Day x 180 day(s)
Indication: Constipation, unspecified
Copay Required:No
Telephone Verbal Order: No
Completed by
Cosign Required: No
on 07/26/2019 08:58
Page 020 of 148
Withheld pursuant to exemption
(b)(6); (b)(7)(A) (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07126,2019 08:58 by
Bureau of Prisons NYM
Page I of I
EFTA00073851
Bureau of Prisons
Health Services
Clinical Encounter - Administrative Note
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318.054
Date of Birth:
01/20/1953
Sex:
Rate WHITE
Facility:
NYM
Note Date:
07/24/2019 16:10
Provider:
Unit:
H01
Cosign Note - Clinical Encounter Cosign encounter performed at Health Services.
Administrative Notes:
ADMINISTRATIVE NOTE 1
Provider:
THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM
2 NIGHTS AGO.
Copay Required:No
Telephone/Verbal Order:
Completed by
Cosign Required: No
24/2019 16:12
1
e 021 of 148
i.co
Withheld
exemption
(b)(6) ; (b) )
, (
)(C)
of the Freedom of Information
Generated 07/24/2019 16:12 by
Bureau of Prisons - NYM
Page 1 of 1
EFTA00073852
Bureau of Prisons
Health Services
Clinical Encounter - Administrative Note
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318.054
Date of Birth:
01/20/1953
Sex:
Rare-WHITE
Facility:
NYM
Note Date:
07/24/2019 16:10
Provider:
Unit:
H01
Cosign Note - Clinical Encounter Cosign encounter performed at Health Services.
Administrative Notes:
ADMINISTRATIVE NOTE 1
Provider:
THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM
2 NIGHTS AGO.
Copay Required:No
Telephone/Verbal Order:
Completed by
Cosign Required: No
24/2019 16:12
1
il
e 022 of 148
p
Withheld
o exemption
(b)(6) ; (b)
, (
)(C)
of the Freedom of Information
Generated 07/24/2019 16:12 by
Bureau of Prisons - NYM
Page 1 of 1
EFTA00073853
Bureau of Prisons
Health Services
See Amendment
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/26/2019 08:57
Facility:
NYM
Amendment made to this note by
on 07/26/2019 08:58.
Page 023 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Bureau of Prisons - NYM
EFTA00073854
Bureau of Prisons
Health Services
Clinical Encounter - Administrative Note
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318.054
Date of Birth:
01/20/1953
Sex:
m
Rare•WHITE
Facility:
NYM
Note Date:
07/24/2019 15:10
Provider:
Unit:
H01
Admin Note - General Administrative Note encounter performed at Health Services.
Administrative Notes:
ADMINISTRATIVE NOTE 1
Provider:
PATIENT WAS OFFERED TO HAVE AN OPTOMETRIST EVALUATION. HE REFUSED. REFUSAL FORM
SIGNED.
Copay Required:No
TelephoneNerbal Order: No
Completed by
Cosign Required: No
on 07/24/2019 15:17
Page 024 of 148
Withheld pursuant to exemption
(b)(6) (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07/24/2919 15:17 by
Bureau of Prisons - NYM
Page 1 of 1
EFTA00073855
Bureau of Prisons
Health Services
Clinical Encounter
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Facility: NYM
Encounter Date: 07/24/2019 13:08
Provider:
Unit:
H01
Mid Level Provider Follow up Visit encounter performed at Receiving & Discharge.
SUBJECTIVE:
COMPLAINT 1
Provider:
Chief Complaint: Other Problem
Subjective:
I still do not want to talk about. But, between you and me. I think my room mate had to do with
what happened to me. Do not ask me. I am not going to say anything.
Pain:
No
OBJECTIVE:
Temperature:
Date
Tittle
Fa_hienteit
GetSiu_s LOCatiOn
Provider
07/24/2019
13:12 NYM
97.8
36.6 Oral
Pulse:
Date
Time
Rate Per Minute
Location
Rhythm
Provider
07/24/2019 13:12
83
Via Machine
Regular
Page 025 of 148
Blood Pressure:
Date
Time
Value
LocationWithheislamnt to extriiiiivze
Provider
07/24/2019 13:12 NYM 132/89
Right Arm
(b) jtirm(7)(A): (b)Mayegular
SaO2:
of the Freedom of Information and Privacy Act
Date
Time
Value(%) Air
Provider
07/24/2019
13:12 NYM
96 Room Air
Exam:
General
Affect
Yes: Cooperative
Appearance
Yes: Appears Well, Alert and Oriented x 3
No: Appears Distressed. Appears in Pain
Exam Comments
Follow up evaluation done for inmate Epstein.
He does not look in any pain or distress.
He still has the erythema around his neck. Central part of this erythema has some abrasion. Patient does not complaint
of any respiratory problem or distress. He still does not want to explain how the skin injury on his neck happed. he
insinuates that injuries on his neck have to do with his room male. But does not want to talk about it.
ASSESSMENT:
Injury, unspecified. T1490 - Current
PLAN:
Disposition:
Generated 07 24 2019 13.24 by
Bureau of Prisons - NYM
Page 1 of 2
EFTA00073856
Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Encounter Date: 07/24/2019 13:08
Provider:
Reg #:
76318-054
Facility: NYM
Unit:
H01
Follow-up at Sick Call as Needed
Patient Education Topics:
Date Initiated Format
07/24/2019
Counseling
07/24/2019
Counseling
Copay Required:No
Telephone/Verbal Order: No
Completed by
on 07/2412019 13:24
Requested to be cosigned by
Cosign documentation will be displayed on the following page.
Handout/Topic
Access to Care
Preventive Health
Cosign Required: Yes
Page 026 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Provider
Outcome
Verbalizes
Understanding
Verbalizes
Understanding
Generated 07)242019 1324 by
Bureau of Prisons • NYM
Page 2 of 2
EFTA00073857
Bureau of Prisons
Health Services
Cosign/Review
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/24/2019 13:08
Provider:
Facility:
NYM
Cosigned with New Encounter Note by
on 07/24/2019 16:10.
Page 027 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Bureau of Prisons NYM
EFTA00073858
Bureau of Prisons
Health Services
Clinical Encounter
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Facility: NYM
Encounter Date: 07/23/2019 06:20
Provider:
Unit:
H01
Injury Assessment Non-work related encounter performed at Health Services.
SUBJECTIVE:
INJURY 1
Provider:
Date of Injury:
07/23/2019 01:27
Date Reported for Treatment:
07/23/2019 08:25
Work Related:
No
Work Assignment:
UNASSG
Pain Location:
Pain Scale:
0
Pain Qualities:
Where Did Injury Happen (Be specific as to location):
Special Housing Unit Z05-Cell 124 L
Cause of Injury (Inmate's Statement of how injury occurred):
"I do not know. Just went to drink a little water and wake up snorting".
Symptoms (as reported by inmate):
None
Page 028 of 148
OBJECTIVE:
Withheld pursuant to exemption
Temperature:
u(b)aar tigr)i(A) ; (b)(71(C) .
Date
Time
Fahrenheit Cglsi_s
Provider
07 23 2019
06:30 NYM
91.Se FreeSOPA o(ynibrmation and PthsvOlip1Y. MLP
Pulse:
Dale
Time
Rate Per Minute
Location
07723/2019 06:30
92
Via Machine
Regular
Respirations:
Date
Time
Rate Per Minute Provider
07/23/2019
06:30 NYM
16
Blood Pressure:
Date
Time
Value
Location
Position
07/23/2019 06:30 NYM 140/85
Right Arm
Sitting
Adult-regular
SaO2:
Date
Time
Value(%) Air
Provider
07/23/2019
06:30 NYM
96 Room Air
Rhy►hm
Provider
Cuff Size
Provider
Exam:
General
Affect
Yes: Cooperative
Appearance
Yes: Appears Well, Alert and Oriented x 3
No: Appears Distressed, Lethargic. Dyspneic, Appears in Pain, Pallor, Cyanotic, Diaphoretic, Disheveled,
Generated 0712312019 09.05 by
Bureau of Prisons NYM
Page 1 of 2
EFTA00073859
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
R
: WHITE
Facility: NYM
Encounter Date: 07/23/2019 06:20
Provider:
Unit:
H01
Exam:
Acutely III
Pulmonary
Auscultation
Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally
No: Crackles, Rhonchi, Wheezing
Exam Comments
Inmate for injury report as requested by Operational Lt.
He is ambulatory, oriented x 3. In not apparent distress, smiling during this clinical encounter. Alleges. that he does not
know what happened. Can not explain the marks on his neck. Responded: "I don't know".
He does not want to talk of the events leading to the marks on his neck.
He does not look in any distress or pain.
Has an circular line of erythema at the base of the neck. Reaching 2/3 of the neck circumference, 2 inches wide, sparing
the back of the neck. Has one section of this erythema in the front with marks of friction.
No inflammation, no deformities, no hematomas. no lacerations, no tenderness. Patient moving his neck without any
restriction. Denies having any pain or discomfort. Denies any respiratory problem.
Has another small erythema on left knee about 2cm in diameter(mild).
As per information from custody staff inmate Epstein was found in his cell with a rope around his neck and sitting on the
floor.
Inmate is currently placed on suicide watch.
ASSESSMENT:
Page 029 of 148
Injury, unspecified, T1490 - Current -'iO self inflicted injuries.
Withheld pursuant to exemption
PLAN:
(b)(6). (b)(7)(A) (b)(7)(C)
Disposition:
Follow-up at Sick Call as Needed
Placed on Suicide Watch
Follow-up in 2-4 Hours
of the Freedom of Information and Privacy Act
Other:
For follow up with psychology service.
Patient Education Topics:
Date Initiated Format
Handout/Topic
Provider
Outcome
07/23/2019
Counseling
Access to Care
Verbalizes
Understanding
07/23/2019
Counseling
Plan of Care
Verbalizes
Understanding
Copay Required:No
Cosign Required: Yes
Telephone/Verbal Order: No
Completed by
on 07`23 2019 09:05
Requested to be cosigned by
Cosign documentation will be displayed on the following page.
Generated 07/23/2019 09:05 by
Bureau of Prisons - NYM
Page 2 of 2
EFTA00073860
Bureau of Prisons
Health Services
Cosign/Review
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/23/2019 06:20
Provider:
Facility:
NYM
Cosigned by
on 07/23/2019 15:44.
Page 030 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Bureau of Prisons NYM
EFTA00073861
Bureau of Prisons
Health Services
Clinical Encounter
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/14/2019 17:36
Provider
Reg #:
76318-054
M
Race: WHITE
Facility: NYM
Unit:
Z05
Chronic Care 14 Day Physician Eval encounter performed at Health Services.
SUBJECTIVE:
COMPLAINT 1
Provider:
Chief Complaint: ENDOLIPID
Subjective:
66 YR OLD WHITE MALE WITH HX OF
HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS
800 , NOW 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE
MEDS DUE TO THEIR GI SIDE EFFECTS.
HX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP
MACHINE. STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED.
STATES THE FBI LOKELY HAS
L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE
LOWER EXTREMITIES.
SURGICAL HX: NONE
MENTAL HEALTH HX: NONE
Pain:
Yes
Pain Assessment
Date:
07/12/2019 13:25
Page 031 of 148
Location:
Back-Middle
Withheld pursuant to exemption
Quality of Pain:
Shooting
Pain Scale:
5
(b)(6); (b)(7)(A); (b)(7)(C)
Intervention:
MEDRerl-take86‘616f Information and Privacy Act
Trauma Date'Year:
Injury:
Mechanism:
Onset:
5+ Years
Duration:
5+ Years
Exacerbating Factors: NO EXERCISE
Relieving Factors:
MEDROL DOSE PACK
Reason Not Done:
Comments:
Seen for clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid
Added to clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid
OBJECTIVE:
Exam:
General
Appearance
Yes: Appears Well, Alert and Oriented x 3
No: Appears Distressed. Dyspneic. Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic,
Disheveled, Unkempt. Acutely III
Nutrition
No: Appears Obese
Generated 07/1422019 18:11 by
Bureau of Prisons - NYM
Page 1 of 3
EFTA00073862
Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Encounter Date: 07/14/2019 17:36
Provider:
Reg #:
76318-054
Facility: NYM
Unit:
Z05
Exam:
Eyes
General
Yes:
, Extraocular Movements Intact
Pulmonary
Auscultation
Yes: Clear to Auscultation
Cardiovascular
Auscultation
Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2
No: Milt
Abdomen
Auscultation
Yes: Normo-Active Bowel Sounds
Palpation
Yes: Within Normal Limits
Musculoskeletal
Tibia / Fibula
No: Edema
Back
Yes: Tenderness
Neurologic
Cranial Nerves (CN)
Yes: Within Normal Limits
Motor System-General
Yes: Normal Exam
ASSESSMENT:
Page 032 of 148
Withheld pursuant to exemption
(b)(6) (b)(7)(A) , (b)(7)(C)
of the Freedom of Information and Privacy Act
Constipation, unspecified, K5900 - Current
Hyperlipidemia, unspecified, E785 - Current
Low back pain, M545 - Current
Neuralgia and neuritis, unspecified, M792 - Current
Sleep apnea, G4730 • Current
PLAN:
New Medication Orders:
RAE
Medication
Omega 3 ( Vascepa) 1 GM Capsule
Order Date
07/14/2019 17:36
Indication: Hyperlipidemia, unspecified
New Laboratory Requests:
Details
Frequency
Lab Tests-H-Hemoglobin A1C
One Time
Lab Tests-L-Lipid Profile
Additional Information:
Generated 07/14/2019 18:11 by
Prescriber Order
TAKE 2 CAPS Orally - Two
Times a Day x 180 day(s) --
TAKE WITH FOOD.
Due Date
Priority
10/10/2019 00:00
Routine
Bureau of Prisons - NYM
Page 2 of 3
EFTA00073863
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/14/2019 17:36
Provider
Reg #:
76318-054
M
Race: WHITE
Facility: NYM
Unit:
Z05
FASTING.
Lab Tests-H-Hep B surface Ab
Lab Tests-H-Hep B surface Ag
Lab Tests-H-Hep C Ab
Lab Tests-H-Hepatic Profile
Schedule:
One Time
08/08/2019 00:00
Routine
Activity
Date Scheduled
Scheduled Provider
Clinical Encounter
07/24/2019 00:00 Optometrist
66 YR OLD MALE FOR ROUTINE SCREENING.
Chronic Care Visit
01/07/2020 00:00 Mid-Level Provider
6 MONTH F/U.
Chronic Care Visit
07/01/2020 00:00 Physician 01
Other:
PENDING EKG AND FOBT. CXR WAS REFUSED.
Patient Education Topics:
Qate_initiated Format
Handout/Topic
07/14/2019
Counseling
Diagnosis
Copay Required: No
Cosign Required: N9age 033 of 148
Telephone Verbal Order: No
Withheld pursuant to exemption
Completed by
011 07 14.'2019 18:11
(b)(6); (b)(7)(A): (b)(7)(C)
of the Freedom of Information and Privacy Act
Provider
Outcome
Verbalizes
Understanding
Generated 07/14/2019 18:11 by
Bureau of Prisons - NYM
Page 3 of 3
EFTA00073864
Bureau of Prisons
Health Services
Clinical Encounter
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/12/2019 13:10
Provider
M
Race: WHITE
Reg #:
76318-054
Facility: NYM
Unit:
Z05
Chronic Care 14 Day Physician Eval encounter performed at Health Services.
SUBJECTIVE:
COMPLAINT 1
Provider:
Chief Complaint: ENDOiLIPID
Subjective:
66 YR O
HITE MALE WITH HX OF
HYPER
CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS
800 .
STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE
MED
EIR GI SIDE EFFECTS.
HX OF
UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP
MACHINE.
HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED.
STATES TH
Y HAS
L4 - L5 SEVERE
SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE
LOWER EXTREM
S.
SURGICAL HX: NONE
MENTAL HEALTH HX:
Pain:
Yes
Pain Assessment
Date:
Location:
Quality of Pain:
Pain Scale:
Intervention:
MEDRatlig:ISielaitWlef Information
Trauma Date'Year:
Injury:
Mechanism:
Onset:
5+ Years
Duration:
5+ Years
Exacerbating Factors: NO EXERCISE
Relieving Factors:
MEDROL DOSE PACK
Reason Not Done:
Comments:
07/1212019 13:25
C
Se 034 of 148
Back-Middle
Withheld bt4o
exemption
Shooting
5
(b)(6): (b)(7)
, (' - )(C)
Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology
Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology
OBJECTIVE:
Exam:
General
Appearance
Yes: Appears Well, Alert and Oriented x 3
No: Appears Distressed. Dyspneic. Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic,
Disheveled. Unkempt. Acutely III
Nutrition
No: Appears Obese
Generated 07ft2/2019 14:20 by
Bureau of Prisons - NYM
Page 1 of 3
EFTA00073865
Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Encounter Date: 07/12/2019 13:10
Provider:
Reg #:
76318-054
Facility: NYM
Unit:
Z05
Exam:
Eyes
General
Yes:
, Extraocular Movements Intact
Pulmonary
Auscultation
Yes: Clear to Auscultation
Cardiovascular
Auscultation
Yes: Regular Rat
Rhythm (RRR), Normal S1 and S2
No: Mit
Abdomen
Auscultation
Yes: Normo-Active
Palpation
Yes: Within Normal Limits
Musculoskeletal
Tibia / Fibula
No: Edema
Back
Yes: Tenderness
Neurologic
Cranial Nerves (CN)
Yes: Within Normal Limits
Motor System-General
Yes: Normal Exam
ASSESSMENT:
e 035 of 148
le
o exemption
(b)(6) : (b)( )
)(C)
of the Freedom of Information
Constipation, unspecified, K5900 - Current
Hyperlipidemia, unspecified, E785 - Current
Low back pain, M545 - Current
Neuralgia and neuritis, unspecified, M792 - Current
Sleep apnea, G4730 - Current
PLAN:
New Medication Orders:
Medication
Order Date
Magnesium Hydroxide Susp
07/12/2019 13:10
Indication: Constipation, unspecified
MethylPREDNISolone Tab 4 MG ( Dose
07/12/2019 13:10
Pack 21 tab)
Indication: Neuralgia and neuritis, unspecified
Disposition:
Prescriber Order
30 CC Orally - Two Times a
Day PRN x 2 day(s)
AS DIRECTED Orally - daily x
6 day(s)
Generated 07/12/2019 14:20 by
Bureau of Prisons - NYM
Page 2 of 3
EFTA00073866
Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/12/2019 13:10
Provider
M
Race: WHITE
Reg #:
76318-054
Facility: NYM
Unit:
Z05
Follow-up at Sick Call as Needed
Other:
WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP.
Patient Education Topics:
Date Initiated Format
Handout/Topic
07/12/2019
Counseling
Diagnosis
Copay Required:No
Telephone/Verbal Order:
Completed by Beaudouin,
Cosign Required: No
07/12/2019 14:20
4
e 036 of 148
ullo
Withheld
exemption
(b)(6) ; (b) )
, (
)(C)
of the Freedom of Information
Provider
Outcome
Verbalizes
Understanding
Generated 07:12 2019 1420 by
Bureau of Prisons - NYM
Page 3 of 3
EFTA00073867
Bureau of Prisons
Health Services
Clinical Encounter
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/12/2019 13:10
Provider
M
Race: WHITE
Reg #:
76318-054
Facility: NYM
Unit:
Z05
Chronic Care 14 Day Physician Eval encounter performed at Health Services.
SUBJECTIVE:
COMPLAINT 1
Provider:
Chief Complaint: ENDO/LIPID
Subjective:
66 YR 0
HYPER
800 .
MED
HX OF
MACHINE.
STATES TH
L4 - L5 SEVERE
LOWER EXTREM
S.
SURGICAL HX: NONE
MENTAL HEALTH HX:
Pain:
Yes
Pain Assessment
Date:
Location:
Quality of Pain:
Pain Scale:
Intervention:
Trauma Date Year:
Injury:
Mechanism:
Onset:
Duration:
Exacerbating Factors:
Relieving Factors:
Reason Not Done:
Comments:
HITE MALE WITH HX OF
CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS
STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE
EIR GI SIDE EFFECTS.
UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP
HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED.
Y HAS
SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE
07/12/2019 13:25
Back-Middle
Shooting
5
Withheld
e 037 of 148
o exemption
(b)(6): (b)(
)(C)
MEDRQ.tfAClb€e86Fil6f Information
5+ Years
5+ Years
NO EXERCISE
MEDROL DOSE PACK
Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology
Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology
OBJECTIVE:
Exam:
General
Appearance
Yes: Appears Well, Alert and Oriented x 3
No: Appears Distressed. Dyspneic. Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic,
Disheveled. Unkempt. Acutely III
Nutrition
No: Appears Obese
Generated 07/12/2019 14:20 by
Bureau of Prisons - NYM
Page 1 of 3
EFTA00073868
Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Encounter Date: 07/12/2019 13:10
Provider:
Reg #:
76318-054
Facility: NYM
Unit:
Z05
Exam:
Eyes
General
Yes:
, Extraocular Movements Intact
Pulmonary
Auscultation
Yes: Clear to Auscultation
Cardiovascular
Auscultation
Yes: Regular Rat
Rhythm (RRR), Normal S1 and S2
No: Milt
Abdomen
Auscultation
Yes: Normo-Active
Palpation
Yes: Within Normal Limits
Musculoskeletal
Tibia / Fibula
No: Edema
Back
Yes: Tenderness
Neurologic
Cranial Nerves (CN)
Yes: Within Normal Limits
Motor System-General
Yes: Normal Exam
ASSESSMENT:
e 038 of 148
exemption
(b)(6) ; (b)(7)
(
)(C)
of the Freedom of Information
Constipation, unspecified, K5900 - Current
Hyperlipidemia, unspecified, E785 - Current
Low back pain, M545 - Current
Neuralgia and neuritis, unspecified, M792 - Current
Sleep apnea, G4730 - Current
PLAN:
New Medication Orders:
8/iff
Medication
Order Date
Magnesium Hydroxide Susp
07/12/2019 13:10
Indication: Constipation, unspecified
MethylPREDNISolone Tab 4 MG ( Dose
07/12/2019 13:10
Pack 21 tab)
Indication: Neuralgia and neuritis, unspecified
Disposition:
Prescriber Order
30 CC Orally - Two Times a
Day PRN x 2 day(s)
AS DIRECTED Orally - daily x
6 day(s)
Generated 07/12/2019 14:20 by
Bureau of Prisons - NYM
Page 2 of 3
EFTA00073869
Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Facility: NYM
Encounter Date: 07/12/2019 13:10
Provider:
Unit:
Z05
Follow-up at Sick Call as Needed
Other:
WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP.
Patient Education Topics:
Date Initiated Format
07/12/2019
Counseling
Copay Required:No
Telephone/Verbal Order:
Completed by Beaudouin,
Handout/Topic
Provider
Outcome
Diagnosis
Verbalizes
Understanding
Cosign Required: No
07/12/2019 14:20
4
039 of 148
Withheld
L
e
o exemption
e
(b)(6) , (b)( )
)(C)
of the Freedom of Information
Generated 07:12,2019 14:20 by
Bureau of Prisons - NYM
Page 3 of 3
EFTA00073870
Bureau of Prisons
Health Services
See Amendment
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/14/2019 17:36
Facility:
NYM
Amendment made to this note by
on 07/14/2019 18:11.
Page 040 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Bureau of Prisons - NYM
EFTA00073871
Bureau of Prisons
Health Services
Clinical Encounter - Administrative Note
Inmate Name:
Date of Birth:
Note Date:
EPSTEIN, JEFFREY EDWARD
01/20/1953
Sex:
Rana. WH ITF
07/12/2019 09:06
Provider:
Reg #:
Facility:
Unit:
76318.054
NYM
Z05
Admin Note - Orders encounter performed at Health Services.
Administrative Notes:
ADMINISTRATIVE NOTE 1
Provider:
PATIENT REQUESTED TO HAVE A COLACE RX , INSTEAD OF TEH BISACODYL FOR CONSTIPATION.
New Medication Orders:
fixE
Medication
Order Date
Docusate Sodium Capsule
07/12/2019 09:06
Indication: Constipation, unspecified
Discontinued Medication Orders:
Bx#
Medication
Order Date
121757-NYM
Bisaoodyl E.C. 5 MG TAB
07/12./2019 09:06
Discontinue Type:
When PharmacThicaises
Di 148
Discontinue Reason:discoggilhheld pursuant to exemption
Indication:
Copay Required:No
TelephoneNerbal Order: No
Completed by
(b)(6) : (b)(7)(A), (b)(7)(C)
Cosign Required: No
of the Freedom of Information and Privacy Act
on 07/12/2019 09:10
Prescriber Order
TAKE ONE 100 MG CAP Orally
- Two Times a Day x 30 day(s)
Prescriber Order
Take one tablet (5 MG) by mouth
at bedtime AS NEEDED for 10
days
Generated 07/122019 09:10 by
Bureau of Prisons NYM
Page 1 of 1
EFTA00073872
Bureau of Prisons
Health Services
Clinical Encounter - Administrative Note
Inmate Name:
Date of Birth:
Note Date:
EPSTEIN, JEFFREY EDWARD
01;201953
Sex:
07/07/2019 00:17
Provider:
Reg IS:
76318-054
Rant, WHITE
Facility:
NYM
Unit:
E06
Cosign Note - Intake Cosign encounter performed at Health Services.
Administrative Notes:
ADMINISTRATIVE NOTE 1
Provider:
MED CL:1
NO CCC APPT.
Discontinued Laboratory Requests:
Details
Frequency
Due Date
Priority
Lab Tests-H-Hemoglobin AIC
One Time
08/05/2019 00:00
Routine
Lab Tests-C-CBC w/diff
Lab Tests-L-Lipid Profile
Lab Tests-C-Comprehensive Metabolic Profile
(CMP)
Lab Tests-U-Urinalysis w/Reflex to Microscopic
Additional Information:
66 y/o male, elevated BP
Labs requested to be reviewed by:
BeauoCNC, Ckg*ti reflb
New Laboratory Requests:
Withheld pursuant to exemption
Details
Frequency
Due Date
Priority
Chronic Care Clinics-Diabetic-CBC w/diff
(KM; Tlip(f)(A) (b)(7)(C) 07/25/2019 00:00
Routine
Chronic Care Clinics-Diabetic-Lipid Profile
Chronic Care Clinics-Diabetic-HemObOgiffrAggpm of Information and Privacy Act
Lab Tests-H-HIV 1/2
Lab Tests-I-RPR
Chronic Care Clinics-Diabetic-Comprehensive
Metabolic Profile (CMP)
New Radiology Request Orders:
Deals
Frequency
End Date
Due Date
Priority
General Radiology-Chest-2 Views
One Time
07/25/2019
Routine
Specific reason(s) for request (Complaints and findings):
66 YR OLD MALE WITH NO PMHX REFERRED FOR ROUITNE CXR.
Copay Required:No
TelephoneNerbal Order: No
Completed by
Cosign Required: No
on 07/07/2019 00:30
Generated 07/07/2019 00:30 by
Bureau of Prisons NYM
Page I of I
EFTA00073873
Bureau of Prisons
Health Services
Health Screen
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/06/2019 21:38
Provider:
PA-C
Facility:
NYM
Seizures:
Denied
Diabetes:
Denied
Cardiovascular:
Denied
CVA:
Denied
Hypertension:
Denied
Respiratory:
Denied
Sickle Cell Anemia:
Denied
Carcinomatymphoma:
Denied
Allergies:
Denied
PPD Administration:
Date!lime: 07 06 2019 21:39
Provider:
PA-C
Location: Right Forearm
Page 043 of 148
Drug Mfg: Sanofi Pasteur
Withheld pursuant to exemption
Lot Number: C5474BA
Dosage: 0.1mL
(b)(6) (b)(7)(A): (b)(7)(C)
Route: ID
of the Freedom of Information and Privacy Act
Exp Dt: 1012020
Comments:
Tuberculosis:
Hx of Previous Disease: No
Blood-tinged Sputum: No
Night Sweats: No
Weight Loss: No
Fever: No
Cough:No
Comments:
Generated 07i0612019 21:56 by
PA C
Bureau of Prisons NYM
Page 1 of 6
EFTA00073874
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/06/2019 21:38
Provider:
PA-C
Facility:
NYM
Infectious Disease Risk Factors:
IV Drug Use: No
IV Drug Use Needles:
Sexual Partner IV Drug Use: No
Sexual Partner IV Drug Use Needles:
Female Sexual Partners (Last 5 Yrs): 10+
Male Sexual Partners (Last 5 Yrs): 0
Condom Use: Sometimes
Sexual Contact With HIV+ Individual: No
Blood Product Transfusion: No
Travel Outside US: Yes
Tattoos: No
Comments: Born in US
High school diploma
Banker
Traveled to Paris x 3 weeks up until arrest
No tattoos
HIV History:
Page 044 of 148
When Tested:
2019
Withheld pursuant to exemption
Test Result:
Negative
When Diagnosed AIDS:
(b)(6); (b)(7)(A): (b)(7)(C)
Last CD4:
of the Freedom of Information and Privacy Act
Comments:
Hepatitis:
Denied
Other Infectious Diseases:
Syphilis:
No
Syphilis Last Treatment:
N/A
Genital Warts:
No
Chlamydia:
Yes
Gonorrhea:
No
Herpes:
No
Chicken Pox:
Yes
Other:
No
Comments: Chlamydia in 2015, treated
Chicken pox in childhood
Abuse History: Denied
Physical: No
Emotional: No
Sexual: No
Comments: Denies
Generated 07/06/2019 21:56 by
PA-C
Bureau of Prisons NYM
Page 2 of 6
EFTA00073875
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/0672019 21:38
Provider:
PA-C
Facility:
NYM
Mental Health:
Level of Consciousness: Alert and Oriented
Psychomotor Activity: Normal
General Appearance: Normal
Behavior: Cooperative
Mood: Appropriate to Content
Thought Process: Goal Directed
Thought Content: Normal
Hx of Mental Health Treatment: None
Hx of Head Injury: None
Current Mental Health Treatment: No
Current Mental Health Complaint: No
Hx of Loss of Consciousness: No
Hx of Hearing Voices: No
Past History of Suicide Attempt: No
Current Suicide Ideation: No
Suicide Prevention Initiated:No
Page 045 of 148
Comments:
Withheld pursuant to exemption
Substance Use History: Denied
(b)(6); (b)(7)(A): (b)(7)(C)
Current Painful Condition:
Denied
of the Freedom of Information and Privacy Act
Other Health Issues:
Current Medical Conditions:
Other Current Treatments:
Pregnant:
N A
Dental Condition: Denied
Generated 07,06/2019 21:56 by
PAC
Bureau of Prisons NYM
Page 3 of 6
EFTA00073876
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/06/2019 21:38
Provider:
PA-C
Reg #:
Race:
Facility:
76318-054
WHITE
NYM
Observations:
Draining Skin Lesions: No
Signs of Lice: No
Signs of Scabies: No
Signs of Recent Trauma: No
Recent Tattoos: No
Needle Marks: No
Signs of Rash: No
Open Sores: No
Wounds: No
Body Deformities: No
Tremors: No
Sweating: No
Comments:
Pulse:
Date
Time
Rate Per Minute
07/06/2019 21:43
90
Respirations:
Date
Dme
07/06/2019
21:43 NYM
Blood Pressure:
Date
Time
Value
Location
07/06/2019 21:45 NYM 164/90
Right Arm
07/06/2019 21:43 NYM 155/83
Left Arm
SaO2:
Date
Time
Value(%) Air
07/06/2019
21:43 NYM
95 Room Air
Location
Rhythm
Provider
Via Magbi006 of 148
Withheld pursuant to exemption
Rate Per Minute Provider
(b)SW ;41C7g),(ObblibRE )
of the Freedom of Information and Privacy Act
Position
Sitting
Sitting
Cuff Size
Provider
Adult-regular
Adult-regular
Provider
Height:
Date
dm
Inches
Cm
Provider
07/06/2019 21:43 NYM
72.0
182.9
PA-C
Weight:
Date
Time
the
Kg Waist Circum Provider
07/06/2019
21:43 NYM
200.0
90.7
Prosthetic Devices/Equipment: Denied
Potential Items For Follow-up:
Item
Travel Outside US
Other Infectious Disease History
Comments:
I have reviewed 0 pages of intake paperworks
PA-C
PA-C
PA-C
PA-C
PA-C
Generated 07'06,2019 21:56 by
PA-C
Bureau of Prisons NYM
Page 4 of 6
EFTA00073877
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/06/2019 21:38
Provider:
PA-C
Facility:
NYM
Health Problems Newly Identified During This Encounter:
HeatthEroblem
Medication Reconciliation.
The patient's known medication list including OTC items was compiled and compared to new and changed BOP
orders.
Reconciled Medications:
Source
Action
Type
Rx#
Medication
OTC
No known OTCs
Order Detail
New Laboratory Requests:
Details
Frequency
Due Date
Priority
Lab Tests-H-Hemoglobin A1C
One Time
08/05/2019 00:00
Routine
Lab Tests-C-CBC w/diff
Lab Tests-L-Lipid Profile
Lab Tests-C-Comprehensive Metabolic Profile
(CMP)
Lab Tests-U-Urinalysis w/Reflex to Microscopic
Additional Information:
66 ylo male, elevated BP
Labs requested to be reviewed by:
New Non-Medication Orders:
Page 047 of 148
Order
Frequency
.._Dumlloo
Details .
Ordered By
withherb pursuant to exemption
EKG
One Time
66 yio male
PA-C
Order Date:
07'0612OO); (b)(7)(A); (b)(7)(C)
Fecal Occult Blood
One Time
.
3 different stools
of the Freedom of Information ana vrivacy ACT
Order Date:
07/06,2019
Schedule:
Activity
Vision Screen
66 y/o male
PPD Reading
Follow-up
BP check
Date Scheduled
Scheduled Provider
07/06/2019 00:00 Optometrist
07/08/2019 00:00 Nurse
07/09/2019 00:00 Mid-Level Provider
Other:
BP noticed to be elevated.
IM denies Hx of HTN or any significant chronic medical conditions.
He is currently asymptomatic and denies any bodily complaints at this time.
Will recheck BP in 2-3 days.
Disposition:
Follow-up at Sick Call as Needed
To be Evaluated by Provider
Instructed inmate how to obtain medical, dental, and mental health care.
Copay Required:No
Cosign Required: Yes
Telephone/Verbal Order: No
PA-C
Generated 07'06:2019 21:56 by
PA,C
Bureau of Prisons NYM
Page 5 of 6
EFTA00073878
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/06/2019 21:38
Provider:
PA-C
Facility:
NYM
Completed by
PA-C on 07/06/2019 21:56
Requested to be cosigned by
Cosign documentation will be displayed on the following page.
Page 048 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07/06/2019 21:56 by
PA•C
Bureau of Prisons - NYM
Page 6 of 6
EFTA00073879
Bureau of Prisons
Health Services
Cosign/Review
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/06/2019 21:38
Provider:
PA-C
Facility:
NYM
Cosigned with New Encounter Note by
on 07/07/2019 00:17.
Page 049 of 148
Withheld pursuant to exemption
(b)(6); (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Bureau of Prisons NYM
EFTA00073880
Bureau of Prisons
Health Services
History & Physical
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/201 953
Sex:
Encounter Date: 07/09/2019 12:35
Provider
M
R
e: WHITE
Reg #:
76318-054
Facility:
NYM
Unit:
H01
Seizures:
Denied
Diabetes:
Denied
Cardiovascular:
Denied
CVA:
Denied
Hypertension:
Denied
Respiratory:
Denied
Sickle Cell Anemia:
Denied
Carcinoma/Lymphoma:
Denied
Allergies:
Denied
Tuberculosis:
Hx of Previous Disease: No
Blood-tinged Sputum: No
Night Sweats: No
Weight Loss: No
Fever: No
Cough:No
Comments:
Infectious Disease Risk Factors:
IV Drug Use: No
IV Drug Use Needles:
Sexual Partner IV Drug Use: No
Sexual Partner IV Drug Use Needles:
Female Sexual Partners (Last 5 Yrs): 10+
Male Sexual Partners (Last 5 Yrs): 0
Condom Use: Sometimes
Sexual Contact With HIV+ Individual: No
Blood Product Transfusion: No
Travel Outside US: Yes
Tattoos: No
Comments: Born in US
High school diploma
Banker
Traveled to Paris x 3 weeks up until arrest
No tattoos
Page 050 of 148
Withheld pursuant to exemption
(b)(6); (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07,09/2019 13:03 by
Bureau of Prisons - NYM
Page 1 of 13
EFTA00073881
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Encounter Date: 07/09/2019 12:35
Provider:
Reg #:
76318-054
Facility:
NYM
Unit:
H01
HIV History:
When Tested:
2019
Test Result:
Negative
When Diagnosed AIDS:
Last CD4:
Comments:
Hepatitis:
Denied
Other Infectious Diseases:
Syphilis:
No
Syphilis Last Treatment:
N/A
Genital Warts:
No
Chlamydia:
Yes
Gonorrhea:
No
Herpes:
No
Chicken Pox:
Yes
Other:
No
Page 051 of 148
Comments: Chlamydia in 2015, treated
Chicken pox in childhood
Withheld pursuant to exemption
Abuse History: Denied
(b)(6) (b)(7)(A); (b)(7)(C)
Physical: No
Emotional: No
Sexual: No
Comments: Denies
of the Freedom of Information and Privacy Act
Generated 07,09/2019 13:03 by
Bureau of Prisons - NYM
Page 2 of 13
EFTA00073882
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Facility:
NYM
Encounter Date: 07/09/2019 12:35
Provider:
Unit:
H01
Mental Health:
Level of Consciousness: Alert and Oriented
Psychomotor Activity: Normal
General Appearance:Normal
Behavior: Cooperative
Mood: Appropriate to Content
Thought Process: Goal Directed
Thought Content: Normal
Hx of Mental Health Treatment: None
Hx of Head Injury: None
Current Mental Health Treatment: No
Current Mental Health Complaint: No
Hx of Loss of Consciousness: No
Hx of Hearing Voices: No
Past History of Suicide Attempt: No
Current Suicide Ideation: No
Page 052 of 148
Suicide Prevention Initiated:No
Comments:
Withheld pursuant to exemption
Substance Use History: Denied
(b)(6); (b)(7)(A); (b)(7)(C)
Current Painful Condition:
DEtifiltib Freedom of Information and Privacy Act
Other Health Issues:
Current Medical Conditions:
Other Current Treatments:
Pregnant:
N A
Dental Condition: Denied
Generated 07,09/2019 13:03 by
Bureau of Prisons - NYM
Page 3 of 13
EFTA00073883
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Facility:
NYM
Encounter Date: 07/09/2019 12:35
Provider:
Unit:
H01
Observations:
Draining Skin Lesions: No
Signs of Lice: No
Signs of Scabies: No
Signs of Recent Trauma: No
Recent Tattoos: No
Needle Marks: No
Signs of Rash: No
Open Sores: No
Wounds: No
Body Deformities: No
Tremors: No
Sweating: No
Comments:
Page 053 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A): (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07/09/2019 13:03 by
Bureau of Prisons - NMI
Page 4 of 13
EFTA00073884
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Facility:
NYM
Encounter Date: 07/09/2019 12:35
Provider:
Unit:
H01
Immunizations:
Hepatitis A and B (TwinRx) Series Administration: History Unknown, Not Administered
Documented Date: 0709/2019 12:51 EST
Immunization Date:
Provider:
Location:
Drug Mfg:
Lot Number:
Dosage:
Route:
Exp Dt:
Comments:
Measles:Mumps,'Rubella Series Administration: History Unknown, Not Administered
Documented Date: 07/09/2019 12:51 EST
Immunization Date:
Provider:
Page 054 of 148
Location:
Withheld pursuant to exemption
Drug Mfg:
(b)(6) (b)(7)(A); (b)(7)(C)
Lot Number:
of the Freedom of Information and Privacy Act
Dosage:
Route:
Exp Dt:
Comments:
Smallpox Series Administration: History Unknown, Not Administered
Documented Date: 07/09/2019 12:51 EST
Immunization Date:
Provider:
Location:
Drug Mfg:
Lot Number:
Dosage:
Route:
Exp Dt:
Comments:
Tetanus Administration: History Unknown, Not Administered
Documented Date: 07/09/2019 12:51 EST
Generated 07,09/2019 13:03 by
Bureau of Prisons - NYM
Page 5 of 13
EFTA00073885
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Encounter Date: 07/09/2019 12:35
Provider:
Reg #:
76318-054
Facility:
NYM
Unit:
H01
Immunization Date:
Provider:
Location:
Drug Mfg:
Lot Number:
Dosage:
Route:
Exp Dt:
Comments:
Varicella Series Administration: History Unknown, Not Administered
Documented Date: 07/09/2019 12:51 EST
Immunization Date:
Provider:
Location:
Drug Mfg:
Lot Number:
Page 055 of 148
Dosage:
Withheld pursuant to exemption
Route:
(b)(6): (b)(7)(A); (b)(7)(C)
Exp Dt:
of the Freedom of Information and Privacy Act
Comments:
Temperature:
Date
Time
Fahrenheit
Celsius Location
Provider
07/09/2019
12:49 NYM
97.3
36.3 Oral
Pulse:
PAW
lime
Rate Per Minute
Location
Rhythm
Provider
07/09/2019 12:49
82
Via Machine
Regular
Respirations:
Date
Time
Rate Per Minute Provider
07/09/2019
12:49 NYM
16
Blood Pressure:
Date
lime
Value
Location
Position
Cuff Size
Provider
07/09/2019 12:49 NYM 117/66
Right Arm
Sitting
Adult-regular
SaO2:
Date
Time
Value(%) Air
Provider
07/09/2019
12:49 NYM
97 Room Air
Height:
Date
Time
Inches
Cm
Provider
07/09/2019 12:49 NYM
70.0
177.8
Generated 07/09(2019 13:03 by
Bureau of Prisons • NYM
Page 6 of 13
EFTA00073886
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Facility:
NYM
Encounter Date: 07/09/2019 12:35
Provider:
Unit:
H01
Date
Time
inches
Cm
Provider
Weight:
Date
Time
iLt s
07/09/2019
12:49 NYM
194.4
88.2
Prosthetic Devices1Equipment: Denied
Tobacco Usage: Denied
Kg Waist Circum. Provider
General Social History:
Foreign Travel:
Born in USA:
Yes
Country of Birth: USA
Patient Education Assessments:
Date
Ed Yrs Occupation
Learns Best By
Primary Language Barriers to Education
07/09/2019
12 Banker
Speaking/Listening English
None
Family History - Father:
Age at Death: 74
Cause of Death: Diabetes complications
Significant Illnesses:
Page 056 of 148
Diabetes
Withheld pursuant to exemption
Heart Disease
Comments:
(b)(6) (b)(7)(A): (b)(7)(C)
Family History - Mother:
of the Freedom of Information and Privacy Act
Age at Death: 81
Cause of Death: Kidney Failure
Significant Illnesses:
Heart Disease
Comments:
Family History - Sibling:
Number of Siblings: 1
Significant Illnesses:
Comments:
Past Hospitalization:
Reason
Location
When
Acute Appendicitis
Mount Sinai Hospital
1990
Complications: None
Comments:
Head:
Normal: Yes
Comments:
Generated 07/09(2019 13:03 by
Bureau of Prisons - NYM
Page 7 of 13
EFTA00073887
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Facility:
NYM
Encounter Date: 07/09/2019 12:35
Provider:
Unit:
H01
Eyes:
EOMI: Yes
Icterus:No
Conjunctival Inflammation: No
Pupils
Yes
Pupil Size Rt:
Pupil Size Lt:
Pupils Comments:
Fundi Vessels Nicking: No
Fundi Vessels Discs Flat:Yes
Fundi Vessels Discs Sharp Margins: Yes
Fundi Vessels Grounds Abnormal: No
Eyes Comments:
Vision Screen
Blindness:
07/09/2019 12:52
With Corrective
Distance Vision: OD: 100
OS: 70
OU:
OD:
OS
OU:
Near Vision:
OD:
OS:
OU:
OD:
OS:
OU:
Page 057 of 148
Ishihara Color Test:
Withheld pursuant to exemption
Tonometry: L:
Comments: Needs evaluation with optometrist.
Ears:
Right Ear: Canal patent
Left Ear:
Canal patent
Ears Comments:
Nose:
Nares Patent: Yes
Septum Midline: Yes
Septum Intact: Yes
Drainage,Discharge: No
Polyps: No
Nose Comments:
(b)(6). (b)(7)(A). (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07,09/2019 13:03 by
Bureau of Prisons - NYM
Page 8 of 13
EFTA00073888
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
HITE
Encounter Date: 07/09/2019 12:35
Provider:
Reg #:
76318-054
Facility:
NYM
Unit:
H01
Mouth
Lesions:No
Oral/Buccal Mucosa:Yes
Gums Normal: Yes
Tonsils Present:Yes
Tonsils Normal: Yes
Pharynx: Normal Color
Teeth Poor Dentition: No
Teeth Count:Mostly Present
Dentures: No
Mouth Comments:
Cranial Nerves:
Intact
Yes
Cranial Nerves Comments:
Neck:
Full ROM:Yes
Masses Nodes: No
Trachea: Midline
Thyroid: Normal Size
Comments:
Breasts:
Page 058 of 148
Withheld pursuant to exemption
(b)(6); (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Normal: Yes
Masses:No
Tenderness:No
Scars: No
Dimpling:No
Nipple Discharge: No
Nipple Retraction:No
Instructions for Self Breast Exam Given:
Comments:
No
Generated 07,09/2019 13:03 by
Bureau of Prisons - NYM
Page 9 of 13
EFTA00073889
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/09/2019 12:35
Provider
M
R
: WHITE
Reg #:
76318-054
Facility:
NYM
Unit:
H01
Thorax:
Contour Normal:Yes
Increased AP Diameter: No
Asymmetrical Expansion:No
Lungs Clear: Yes
Wheezes: No
Crackles: No
Rhonchi: No
Rates: No
Accessory Muscle Use: No
Comments:
Spine:
Deformity: No
Full ROM:Yes
Tenderness: No
Comments:
Cardiovascular:
Page 059 of 148
RRR: Yes
Withheld pursuant to exemption
Normal S1/S2: Yes
Murmurs: No
(b)(6); (b)(7)(A): (b)(7)(C)
Carotid Bruits: No
of the Freedom of Information and Privacy Act
JVD: No
Arteries:
Right
Left
Radial:
Femoral:
Dorsalis Pedis:
Post. Tibialis:
Comments:
Generated 07,0912019 13:03 by
Bureau of Prisons - NYM
Page 10 of 13
EFTA00073890
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/09/2019 12:35
Provider
HITS
Reg 4:
76318-054
Facility:
NYM
Unit:
H01
Abdomen:
Normal Contour:Yes
Scaphoid: No
Obese: No
Gravid: No
Hernias: No
Bruits: No
Masses:No
Scars: No
Tenderness: No
Organomegaly: No
Active Bowel Sounds: Yes
Comments:
Extremities:
Nails Clubbing: No
Nails Cyanosis: No
Lower Extremity Edema - Right: None
Page 060 of 148
Lower Extremity Edema - Left: None
Atrophy: No
Withheld pursuant to exemption
Amputations: No
(b)(6) ; (b)(7)(A); (b)(7)(C)
Other Deformities: No
Varicosities:No
of the Freedom of Information and Privacy Act
Calf Tenderness:No
Pulse Deficit: No
Strength:
Right
Left
Arm:
Leg:
Full ROM:
Right
Left
Arm:
Yes
Yes
Leg:
Yes
Yes
Comments:
Generated 07,09/2019 13:03 by
Bureau of Prisons - NYM
Page 11 of 13
EFTA00073891
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/09/2019 12:35
Provider
M
R
: WHITE
Reg #:
76318-054
Facility:
NYM
Unit:
H01
Reflexes:
Right
ken
Biceps:
Patellar:
Brachioradialis:
Achilles:
Sensation:
Vibratory: Yes
Light Touch: Yes
Pin Prick: Yes
Comments:
GU:
Chaperoned By:
Rectum: Not Done
Comments: Refused.
Male Genitalia: Not Done
Comments: Refused.
Skin:
Normal:Yes
Rash: No
Redness:No
Abnormal Pigmentation: No
Abnormal Lesions Growths: No
Comments:
Lymphatics:
Adenopathy: No
Comments:
Potential Items For Follow-up:
Item
Travel Outside US
Page 061 of 148
Withheld pursuant to exemption
(b)(6); (b)(7)(A), (b)(7)(C)
of the Freedom of Information and Privacy Act
Other Infectious Disease History
Rectum Not Done
Male Genitalia Not Done
PPD Administration Not Performed
Comments:
Patient has a history of constipation.
Generated 07,0912019 13:03 by
Bureau of Prisons
Page 12 of 13
EFTA00073892
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
M
Race: WHITE
Encounter Date: 07/09/2019 12:35
Provider:
Reg #:
76318-054
Facility:
NYM
Unit:
H01
Cleared For Food Services: Yes
Health Problems Newly Identified During This Encounter:
Health Problem
Constipation, unspecified - Current -
New Medication Orders:
Rx#
MedicaliO_n
Order Date
PreS.Criber Ogler
Bisacodyl E.C. Tablet
07/09/2019 12:35
5 mg Orally at bedtime PRN x 10
day(s)
Indication: Constipation, unspecified
Disposition:
Follow-up at Sick Call as Needed
Instructed inmate how to obtain medical, dental, and mental health care.
Copay Required:No
TelephoneNerbal Order: No
Completed by
Requested to be cosigned by
Cosign documentation will be displayed on the following
062 of 148
Withheld pursuant to exemption
(b)(6); (b)(7)(A): (b)(7)(C)
of the Freedom of Information and Privacy Act
Cosign Required: Yes
on 07 09 2019 13:03
Generated 07,09/2019 13:03 by
Bureau of Prisons - NYM
Page 13 of 13
EFTA00073893
Bureau of Prisons
Health Services
Cosign/Review
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/09/2019 12:35
Provider:
Facility:
NYM
Cosigned by
on 07/11/2019 22:41.
Page 063 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Bureau of Prisons NYM
EFTA00073894
Bureau of Prisons
Health Services
Inmate Local Hospital
Reg #: 76318-054
Inmate Name: EPSTEIN. JEFFREY EDWARD
SENSITIVE BUT UNCLASSIFIED — This information is confidential and must be appropriately safeguarded.
Transfer To:
Transfer Date: 08/10/2019
Health Problems
Health Problem
Status
Hyperlipidemia, unspecified
Current
HYPERTRIGLYCERIDEMIA
Sleep apnea
Current
Essential (primary) hypertension
Current
BY HX.
Constipation. unspecified
Current
Low back pain
Current
Neuralgia and neuritis, unspecified
Current
No Diagnosis
Current
Prediabetes
Current
Injury, unspecified
Current
RIO self inflicted injuries.
Body mass index (BMI) 27.0-27.9, adult
Current
Medications: All medications to be continued until evaLuage
ate °tw
d Joyoaphysician unless otherwise indicated.
P
?
Bolded drugs required for transport.
Docusate Sodium 100 MG Cap Exp: 08/11/264M-AO.pTiSafietbcattroilftia00 MG) by mouth twice daily for 30 days
Docusate Sodium 100 MG Cap Exp: 01/22/2020 SIG: Take one capsule (100 MG) twice daily by mouth with plenty
of water
(b)(6), (b)(7)(A), (b)(7)(C)
Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML Exp: 10/28/2019 SIG: shake well take 10ml by mouth twice
daily AS NEEDED
of the Freedom of Information and Privacy Act
Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by mouth with food
OTCs: Listing of all known OTCs this inmate is currently taking.
None
Pending Appointments
Dale
Time
Activity
Provider
07/24/2019
00:00
Clinical Encounter
Optometrist
01/07/2020
00:00
Chronic Care Visit
Mid-Level Provider
07/01/2020
00:00
Chronic Care Visit
Physician 01
07/09/2020
00:00
PPD Administration
Nurse
Pending Non-Medication Orders:
Order
Order Date
Frequency
Duration Details
EKG
07/06/2019
One Time
66 y/o male
Fecal Occult Blood
07/06/2019
One Time
3 different stools
TB Clearance: Yes
Last PPD Date: 07/09/2019
Induration: 0mm
Last Chest X-Ray Date:
TB Treatment:
TB Follow-up Recommended: No
Sickle Cell:
Sickle Cell Trait/Disease:
No
Results:
Sx free for 30 days: Yes
Generated 08..10;2019 07:00 by
RN
Bureau of Prisons NYM
Page 1 of 2
EFTA00073895
Reg #: 76318-054
Inmate Name: EPSTEIN, JEFFREY EDWARD
SENSITIVE BUT UNCLASSIFIED - This information is confidential and must be appropriately safeguarded.
Limitations/Restrictions/Diets:
Cell: lower bunk --- 10/09/2019
Cleared for Food Service: Yes
Other diet restrictions: FISH ALLERGIES. --- 07/30/2020
Comments:
Allergies
No Known Allergies
Devices / Equipment
C-Pap
Travel:
Direct Travel: No
Travel Restrictions: None
UNIVERSAL PRECAUTIONS OBSERVED WHEN TRANSPORTING ANY INMATE:
Transfer From Institution: NEW YORK MCC
Address 1:
Address 2:
City/State/Zip: NEW YORK. New York 10007
Name/Title of Person Completing Form:
Inmate Name: EPSTEIN, JEFFREY EDWARD
Phone Number:
RN
Date:
08/10/2019
Re ag deglf-P134
DOB:
01/20/1953 Sex:
M
Withheld pursuant to exemption
(b)(6); (b)(7)(A): (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 08r10/2019 07:00 by
RN
Bureau of Prisons NYM
Page 2 of 2
EFTA00073896
Bureau of Prisons
Health Services
Vitals All
Begin Date: 07/06/2019
Reg #:
76318-054
End Date:
05/11/2020
Inmate Name: EPSTEIN, JEFFREY EDWARD
Temperature:
Date
07/24/2019
Time
Fahrenheit
13:12 NYM
97.8
Celsius Location
Provider
36.6 Oral
Orig Entered: 07/24/2019 13:14 EST
07/23/2019
06:30 NYM
97.5
36.4 Oral
Orig Entered: 07/23/2019 08:33 EST
07/09/2019
12:49 NYM
97.3
36.3 Oral
Orig Entered: 07/09/2019 12:51 EST
Pulse:
Date
Time
07/30/2019 13:02
Rate Per Minute
Location
Rhythm
Provider
94
Orig Entered: 07/30/2019 13:04 EST
07/30/2019 09:40
88
Orig Entered: 07/30/2019 13:04 EST
07/30/2019 09:30
87
Orig Entered:
07/28/2019 20:28
Orig Entered:
07/28/2019 06:57
Orig Entered:
07/24/2019 13:12
Orig Entered:
07/23/2019 06:30
Orig Entered:
07/09/2019 12:49
Orig Entered:
07/06/2019 21:43
Orig Entered:
Respirations:
Date
07/30/2019
Orig
07/28/2019
Orig
07/28/2019
Orig
07/23/2019
Orig
07/09/2019
Via Machine
Via Machine
07/30/2019 12:59 EST Beaul349014%thhieD
pursuant to "'remotion
07/28/2019 20:29 EST L
RN
82 (b)(6): (b)(7)(A): (b)(7)(C)
07/28/201:#04:flet4Tm gfzibielCi9atikthstiRti lacy Act
83
Via Machine
Regular
07/24/2019 13:14 EST
92
Via Machine
Regular
07/23/2019 08:33 EST
82
Via Machine
Regular
07/09/2019 12:51 EST
90
Via Machine
07/06/2019 21:48 EST
PA-C
Time
09:30 NYM
Rate Per Minute Provider
Entered: 07/30/2019 12:59 EST
20:28 NYM
12
14
RN
Entered: 07/28/2019 20:29 EST
RN
06:57 NYM
14
RN
Entered: 07/28/2019 06:58 EST
RN
06:30 NYM
16
Entered: 07/23/2019 08:33 EST •
12:49 NYM
16
PA-C
RN
RN
Generated 05/11/2020 09:57 by
OGC
Bureau of Prisons • DAN
Page 1 of 3
EFTA00073897
Begin Date: 07/06/2019
Reg #:
76318.054
End Date:
05/11/2020
Inmate Name: EPSTEIN, JEFFREY EDWARD
Generated 05/11/2020 09:57 by
Date
Time
Rate Per Minute Provider
Orig Entered: 07/09/2019 12:51 EST
07/06/2019
21:43 NYM
15
PA-C
Orig Entered: 07/06/2019 21:48 EST
PA-C
Blood Pressure:
Date
lime
Value
07/30/2019 13:02 NYM 114/84
Orig Entered:
07/30/2019 09:40 NYM
Orig Entered:
07/30/2019 09:30 NYM
Orig Entered:
07/28/2019 20:28 NYM
Orig Entered:
07/28/2019 06:57 NYM
Orig Entered:
07/24/2019 13:12 NYM
Orig Entered:
07/23/2019 06:30 NYM
Orig Entered:
07/09/2019 12:49 NYM
Orig Entered:
07/06/2019 21:45 NYM
Orig Entered:
07/06/2019 21:43 NYM
Orig Entered:
Blood Glucose:
Date
Time
08/04/2019
08:30
Orig Entered:
08/02/2019
06:30
Orig Entered:
08/01/2019
06:30
Location
Position
Cuff Size
Provider
Left Arm
Standing
07/30/2019 13:04 EST
125/60
Right Arm
Standing
07/30/2019 13:04 EST
108/86
Left Arm
Sitting
07/30/2019 12:59 EST
157/91
07/28/2019 20:29 EST
RN
138/80
07/28/2019 06:58 EST
RN
132/89
Right Arm
Sitting
Adult-regular
07/24/2019 13:14 EST
140/85
Right Arm
067 of 148"un-regular
07/23/2019 08:33 EST
117/66
Right Pre
%lair o exenli8n.
u
reg lar
07/09/2019 12:51 ESTO:464g(Ii0(704914b)(7)(C)
164/90
RiVt Arm
Sitting.
Adult-regular
07/06/201)9 t21:41;egtr
$an8Privacy Act
155/83
Left Arm
07/06/2019 21:48 EST
Sitting
Value (mg/dO
type
156
Non-Fasting
08/04/2019 09:08 EST
97
Non-Fasting
08/02/2019 08:16 EST
103
Non-Fasting
Orig Entered: 08/01/2019 09:00 EST
Adult-regular
PA-C
07/31/2019
06:15
108
Non-Fasting
Orig Entered: 07/31/2019 08:36 EST
Sa02:
Date
07/30/2019
lime
Value(%) Air
09:30 NYM
98 Room Air
Orig Entered: 07/30/2019 12:59 EST
07/28/2019
20:28 NYM
98
Orig Entered: 07/28/2019 20:29 EST
07/28/2019
06:57 NYM
98
OGC
PA-C
PA-C
Regular Insulin
Provider
RN
Provider
Bureau 01 Prisons • DAN
RN
RN
RN
RN
RN
RN
Page 2 of 3
EFTA00073898
Begin Date: 07/06/2019
End Date:
05/11/2020
Reg #:
76318.054
Inmate Name: EPSTEIN, JEFFREY EDWARD
Date
Time
Value(%) Air
Provider
Orig Entered: 07/28/2019 06:58 EST
RN
07/24/2019
13:12 NYM
96 Room Air
Orig Entered: 07/24/2019 13:14 EST
07/23/2019
06:30 NYM
96 Room Air
Orig Entered: 07/23/2019 08:33 EST
07/09/2019
12:49 NYM
97 Room Air
Orig Entered: 07/09/2019 12:51 EST
07/06/2019
21:43 NYM
95 Room Air
Orig Entered: 07/06/2019 21:48 EST
PA-C
Height:
Date
lime
Inches
Cm
Provider
07/09/2019 12:49 NYM
70.0
177.8
Orig Entered: 07/09/2019 12:51 EST
07/06/2019 21:43 NYM
72.0
182.9
Orig Entered: 07/06/2019 21:48 EST
PA-C
PA-C
PA-C
Weight:
Date
Time
the
Kg Waist Circum. Provider
07/30/2019
09:30 NYM
194.2
88.1
Page 068 oinadouin, Robert MD
Orig Entered: 07/30/2019 12:59 Reahhaelamaiscial RobleMpffibn
07/09/2019
12:49 NYM
194.4
88.2 (b)(6 Ha 7 A;
Orig Entered: 07/09/2019 12:51 EST
07/06/2019
21:43 NYM
266.81e FroWyrn o
ormation angeritaiMWA-C
Orig Entered: 07/06/2019 21:48 EST
PA-C
Generated 05/11/2020 09:57 by
OGC
Bureau of Prisons • DAN
Page 3 of 3
EFTA00073899
Bureau of Prisons
Health Services
PPDs
Reg #: 76318-054
Inmate Name: EPSTEIN, JEFFREY EDWARD
Admin:
Location
07/06/2019 21:39
Right Forearm
Orig Entered: 07/06/2019 21:43 EST
Total: 1
Provider
PA-C
PA-C
Reading•
Induration
Provider
07/09/2019 12:47
0 mm
Orig Entered: 07/09/2019 12:47 EST
Page 069 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Generaled 05/11/2020 09:57 by
OGC
Bureau of Prisons DAN
Page 1 of 1
EFTA00073900
76316054
EPSTEIN. JEFFREY
Medication Orders
Medication Administration Record
JULY 2019
Time
1
2
3 4
5 6
7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Ord. Date
0730'19
I4 21
Inject regular insulin subcutaneously per
Exp. Dale
sliding scale: twice daily "'pill 'Inc— for 7
0731/9
days
'0.01
NYM
122148-
NYM
Insulin Rog (10 ML) 100 UNITSML Ws
inIN
Ord. Date
07/31/19
'0:00
Inject regular insulin subcutaneously per
Exp. Date
sliding scale: each morning for 7 days "'pill
08.07/9
Ilne—•
09 59
NYM
122160-
NYM
InSoto Reg (10 ML) 100 UNITSSAL In1
1111N
Panp 0T0 of US
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A) : (b)(7)(C)
of the Freedom of Information and Privacy Act
Providers: YJ
Documentation Codes: ORD = Order I NI = Dose Not Indicated
Registration F. 76318-054
Pt. Name: EPSTEIN. JEFFREY
DOB: 01/20153
Report information is current as of the date and time of printing: 05,11-2020 09:57 EST
EFTA00073901
76318-054
EPSTEIN. JEFFREY
Medication Orders
Medication Administration Record
AUGUST 2019
Time
1
2
3 4
5 6
7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Ord. Date
0731,19
10 00
Exp. Dale
08,07,19
09:59
Inject regular insulin subcutaneously per
sliding scale: each morning for 7 days —pill
line—
NYM
122160
NYM
Insuim Rog (10 ML) 100 UNITS ML Iq
PAN
Page 071 of 148
Withheld pursuant to exemption
(b)(6); (b)(7)(A) : (b)(7)(C)
of the Freedom of Information and Privacy Act
Providers: Y..1 =
Documentation Codes: ORD = Order I NI = Dose No1 Indicated
Registration 4. 76318-054
Pt. Name: EPSTEIN. JEFFREY
DOB: 01:20:53
Report information is current as of the date and time of printing: 05:11,2020 09:57 EST
EFTA00073902
Bureau of Prisons
Health Services
Devices and Equipment
Start Date: 07/06/2019
Stop Date:
05/11/2020
Reg #:
76318-054
Inmate Name: EPSTEIN, JEFFREY EDWARD
Device/Equipment
Stan Date
Stop Date
Date Returned
Obtained From
Comments
C-Pap
07/30/2019 14:05 EST
07/30/2019
Personal
PHILIPS RESPIRONICS SYSTEM ONE CPAP
MACHINE.
SERIAL #: P11312813B1ED.
Total: 1
Page 072 of 148
Withheld pursuant to exemption
(b)(6); (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 05/11/2020 09:57 by
OGG
Bureau of Prisons - DAN
Page 1 of 1
EFTA00073903
Bureau of Prisons
Health Services
Pain Management
Begin Date: 07/06/2019
End Date:
05/11/2020
Reg #:
76318-054
Inmate Name: EPSTEIN. JEFFREY EDWARD
Date
Intervention
07/12/2019 13:25
MEDROL DOSE PACK
Orig Entered: 07/12/2019 13:28 EST
Pain Quality
Shooting
Page 073 of 148
Withheld pursuant to exemption
(b)(6) : (b)(7)(A) : (b)(7)(C)
of the Freedom of Information and Privacy Act
Location
Pre
Post
Provider
Back-Middle
5
Generals 0511;2020 0937 by
OGG
Bureau of Prisons DAN
Page 1 of 1
EFTA00073904
Bureau of Prisons
Health Services
Modified Diet Request
Types of Diets:
Clear Liquid
Exp Date:
Low Fat
Exp Date:
Mechanical Soft
Exp Date:
Low Cholesterol
Exp Date:
Low Triglyceride
Exp Date:
Renal
Exp Date:
Full Liquid
Exp Date:
Sodium Controlled
Exp Date:
Snack
Exp Date:
Diabetic
Exp Date:
Calorie Controlled
Exp Date:
X Other:
FISH ALLERGIES.
Exp Date: 07/30/2020
Comments:
Page 074 of 148
EPSTEIN. JEFFREY EDWARD
Inmate Name
Withheld pursuant to exemption
(b)(6); (b)(7)(A): (b)(7)(C)
Health Service Staff
of the Freedom of Ini&AH;4and Privacy Act
07/30/2019
Reg#
Date
Generated 07/30/2019 14:57 by
Bureau of Prisons NYM
Page 1 of 1
EFTA00073905
Bureau of Prisons
Health Services
Allergies
Reg #: 76318-054
Inmate Name: EPSTEIN, JEFFREY EDWARD
Alleray
No Known Allergies
Orig Entered:
Total: 1
07/06/2019 21:40 EST
Date Noted
Reaction
07/06/2019
PA-C
Page 075 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 05/11/2020 09:57 by
OGC
Bureau of Prisons - DAN
Page 1 of 1
EFTA00073906
Bureau of Prisons
Health Services
Patient Education Assessments & Topics
Reg #: 76318-054
Inmate Name: EPSTEIN. JEFFREY EDWARD
Assessments
Assessment
Learns Best By
Primary Language
Years of Education Barriers To Education
Provider
07/09/2019
Speaking/Listening
English
12
None
Orig Entered: 07/09/2019 12:52 EST
Total: 1
Topics
Date Initiated
Form
Handout/Topic
Outcome
Provider
07/30/2019
Counseling
Access to Care
Verbalizes Understanding
Orig Entered: 07/30/2019 13:33 EST
Page 076 of 148
07/30/2019
Counseling
Plan of Care
Withheld pursuant to exempliobalizes Understanding
Orig Entered: 07/30/2019 13:34 EST
(b)(6); (b)(7)(A) : (b)(7)(C)
07/28/2019
Counseling
Plan of
Verbalizes Understanding
om of Information and Privacy Act
Orig Entered: 07/28/2019 07:22 EST
07/28/2019
Counseling
Plan of Care
Verbalizes Understanding
Orig Entered: 07/28/2019 20:30 EST
07/24/2019
Counseling
Access to Care
Verbalizes Understanding
Orig Entered: 07/24/2019 13:23 EST
07/24/2019
Counseling
Preventive Health
Verbalizes Understanding
Orig Entered: 07/24/2019 13:23 EST
07/23/2019
Counseling
Access to Care
Verbalizes Understanding
Orig Entered: 07/23/2019 09:04 EST
07/23/2019
Counseling
Plan of Care
Verbalizes Understanding
Orig Entered: 07/23/2019 09:04 EST
07/14/2019
Counseling
Diagnosis
Verbalizes Understanding
Orig Entered: 07/14/2019 18:11 EST
07/12/2019
Counseling
Diagnosis
Verbalizes Understanding
Generated 05'1112020 09:57 by
OGC
Bureau of Prisons DAN
Page 1 of 2
EFTA00073907
Reg #: 76318-054
Inmate Name: EPSTEIN. JEFFREY EDWARD
Topics
Date Initiated
Format
Handout/Topic
Outcome
Provider
Orig Entered: 07/12/2019 13:33 EST
Total: 10
Page 077 of 148
Withheld pursuant to exemption
(b)(6); (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 0511 2020 0937 by
OGC
Bureau of Prisons DAN
Page 2 ol 2
EFTA00073908
Bureau of Prisons
Health Services
Blood Glucose
Begin Date: 07/06/2019
Reg #:
76318-054
End Date:
05'11:2020
Inmate Name: EPSTEIN. JEFFREY EDWARD
(Reference Range: Random or Fasting 70 - 100.2 hour post-prandial 70 - 140)
Date
Time
Value
Type
08/0412019
08:30 NYM 156
Orig Entered: 08/04/2019 09:08 EST
08/02/2019
06:30 NYM 97
Orig Entered: 08/02/2019 08:16 EST
08/01:2019
06:30 NYM 103
Orig Entered: 08/01/2019 09:00 EST
07:31:2019
06:15 NYM 108
Orig Entered: 07/31/2019 08:36 EST
Total: 4
Non-Fasting
RN
Non-Fasting
Non-Fasting
Non-Fasting
Comments
Page 078 of 148
Withheld pursuant to exemption
(b)(6): (b)(7)(A) : (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 05(11/2020 09:57 by
OGC
Bureau of Prisons DAN
Page I of 1
EFTA00073909
Bureau of Prisons
Health Services
Health Problems
Reg #: 76318-054
Inmate Name: EPSTEIN, JEFFREY EDWARD
Description
Hyperlipidemia, unspecified
07/12/2019 13:48 EST
HYPERTRIGLYCERIDEMIA
Sleep apnea
07/12/2019 13:56 EST
Essential (primary) hypertension
07/30/2019 13:13 EST
BY HX.
Constipation, unspecified
07/09/2019 12:58 EST
Low back pain
07/12/2019 13:30 EST
Neuralgia and neuritis, unspecified
07/12/2019 13:30 EST
No Diagnosis
07/09/2019 10:28 EST
PhD/Chief
Psychologist
Prediabetes
07/30/2019 13:26 EST
Injury, unspecified
07/23/2019 09:04 EST
to self inflicted injuries.
Body mass index (BMI) 27.0.27.9, adult
07/30/2019 13:14 EST
Total: 10
Current
Axis Code Type
Code
Diag. Date Status
ICD-10
E785
07/12/2019 Current
ICD-10
G4730
07/12/2019 Current
ICD-10
110
07/30/2019 Current
Page 079 of .1!
iuu 10
K5900
07/09/2019 Current
Withheld pursuant to exemption
(b)(6); (b)(7)(A): (WA
M545
07/12/2019 Current
of the Freedom of Information and Privacy Act
ICD-10
M792
07/12/2019 Current
I DSM-IV
No Dx
07/09/2019 Current
ICD-10
R7303
07/30/2019 Current
ICD-10
T1490
07/23/2019 Current
ICD-10
Z6827
07/30/2019 Current
Status Date
Generated 05/11/2020 09:57 by
OGC
Bureau of Prisons - DAN
Page 1 of
EFTA00073910
Bureau of Prisons
Health Services
Vision Screens
Reg #: 76318-054
Inmate Name: EPSTEIN. JEFFREY EDWARD
Vision Screen on 07/09/2019 12:52
Blindness:
Distance Vision: OD: 20/100
OS: 20/70
OU:
Near Vision:
OD:
OS:
OU:
With Corrective
Distance Vision: OD:
OS:
OU:
Near Vision:
OD:
OS:
OU:
Present Glasses - Distance
Refraction - Distance
Sphere
Cylinder
Axis
Add
Sphere
Cylinder
Axis
Add
L:
L:
Color Test:
Tonometry:
L:
Comments: Needs evaluation with optometrist.
Orig Entered: 07/09/2019 12:54 EST
e 080 of 148
Withheld pursuant to exemption
(b)(6) (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 05/11/2020 09:57 by
OGC
Bureau of Prisons • DAN
Page 1 of 1
EFTA00073911
Bureau of Prisons
Health Services
Immunizations
Begin Date: 07/06/2019
End Date:
05'11:'2020
Reg It:
76318-054
Inmate Name: EPSTEIN, JEFFREY EDWARD
immunization
Immunization Date
Administered Location
Dosage Drug Mfg
Lot #
Exp Date
Hepatitis A and B (TwinRx)
History Unknown
Orig Entered: 07/09/2019 12:51 EST
Measles/Mumps,Rubella Series
History Unknown
Orig Entered: 07/09/2019 12:51 EST
Smallpox Series
History Unknown
Orig Entered: 07/09/2019 12:51 EST
Tetanus
History Unknown
Orig Entered: 07/09/2019 12:51 EST
Varicella Series
History Unknown
Orig Entered: 07/09/2019 12:51 EST
Total: 5
Page 081 of 148
Withheld pursuant to exemption
(b)(6) : (b)(7)(A) : (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 05111/2020 09:57 by
OGC
Bureau of Prisons DAN
Page 1 of I
EFTA00073912
Bur
^. Prisons
i-lea:`!I Services
iCqc .cal Duty Status
Reg #: 76318-054
in :ate Name: EPSTEIN. JEFFREY EDWARD
Housing Status
confined to the living quarter: t. ', ept _meals
pill line
treatments
Exp. Date:
_
_
on complete bed rest:
bathroom privileges only
Exp. Date:
_
X cell:
_cell on fir . floc,
single cell X lower bunk
airborne infection isolation
Exp. Date:
19: 019
other:
Exp. Date:
Physical Limila: 1/Restriction
all spc s
Hill. 4:
upper body
lower body
CP die ascular exercise:
running _jogging
walking
softball
football
basketball
handball
stationary er ..-ment
other:
Exp. L. le:
F .n. Date:
Eap. Date:
Exp. Date:
May have the following equipment in his / her possession:
Equipment
Start C ite
End Date
Return Date
C-Pap
07
ni 19
PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE.
SERIAL #: P11312813B1ED.
Page 082 of 148
Work Restriction / Limitation:
Cleared for Food Service: Yes
X No Restrictions
Comments: N/A
Withheld pursuant to exemption
(b)(6) (b)(7)(A) (b)(7)(C)
of the Freedom of Information and Privacy Act
Health Services Staff
07/30/2019
Date
Inmate Name:
EPSTEIN, ."3-. -WY EDWARD
Reg #:
76318-054
Quarters:
null
ALL EXPIRATION DATES ctt .F 24:00
Generated 05/11/2020 09:57 by
OGC
C
of Prisons - DAN
Page I of 1
EFTA00073913
Bur :Lit ^. Prisons
l-lea:`!I Services
ih'qc .cal Duty Status
Reg #: 76318-054
in. :ate Name: EPSTEIN. JEFFREY EDWARD
Housing Status
confined to the living quarter:. t.,
ept _meals
pill line
treatments
Exp. Date:
on complete bed rest:
bathroom privileges only
Exp. Date:
X cell:
cell on fir' floc,
single cell X lower bunk
airborne infection isolation
Exp. Date:
4 0.19/ :019
other:
Exp. Date:
Physical Limlio: VRestriction
all spc s
Exp. L. le:
wr 4h
upper body
lower body
F • n. Date:
ca dic ascular exercise: _running _jogging
walking
softball
Eat.). Date:
football
basketball
handball
stationary er ..-ment
other:
May have the following equipment in his / her possession:
Work Restriction / Limitation:
Cleared for Food Service: Yes
X No Restrictions
Comments: N/A
Health Services Staff
Page 083 of 148
Withheld pursuant to exemption
(b)1b). (b)(/)(A), (b)( O(L)
Exp. Date:
07/09/2019
Date
Inmate Name:
EPSTEIN, JEFFREDYtEEPtieed6M of lifferation alf3318#0&14Act Quarters:
null
ALL EXPIRATION DATES ARE ATI' ,..01
Generated 05/11/2020 09:57 by
OGC
Eure;i:i of Prisons - DAN
Page I of 1
EFTA00073914
Bureau of Prisons
Health Services
Medication Summary
Historical
Complex: NYM--NEW YORK MCC
Inmate:
EPSTEIN. JEFFREY EDWARD
Begin Date: 07/06:2019
End Date: 05/11/2020
Reg #:
76318.054
Quarter:
???-????
Medications listed reflect prescribed medications from the begin date to end date on this report.
Allergies:
Denied
Active Prescriptions
Bisacodyl E.C. 5 MG TAB
Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days
Rx#: 121757-NYM
Doctor:
Start: 07/09/19
Exp: 0719119
D/C: 07/12/19
Pharmacy Dispensings: 10 TAB in 307 days
Docusate Sodium 100 MG Cap
Take one capsule (100 MG) by mouth twice daily for 30 days
Rx#: 121823-NYM
Doctor:
Start: 07/12/19
Exp: 08/11/19
D/C: 08/10/19
Pharmacy Dispensings: 60 CAP in 304 days
Page 084 of 148
Docusate Sodium 100 MG Cap
Take one capsule (100 MG) twice daily by moutkVittthet&PU9s0lAktcteexemption
Rx#: 122084-NYM
Doctor: Beaudouin. RobwW (b)(7)(A); (b)(7)(C)
Start: 07/26/19
Exp: 01/22/20
D/C: 0810119
Pharmacy Dispensings: 30 CAP in 290 days
of the Freedom of Information and Privacy Act
Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML
shake well take 2 tablespoonful twice daily by mouth
Rx#: 121835-NYM
Doctor:
Start: 07/12/19
Exp: 07/14/19
Pharmacy Dispensings: 473 ML in 304 days
Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML
shake well take 10ml by mouth twice daily AS NEEDED
Rx#: 122150-NYM
Doctor:
Start: 07/30/19
Exp: 10/28/19
D/C: 08/10/19
Pharmacy Dispensings: 473 ML in 286 days
methylPREDNISolone 4 MG Tab [ 21 count Pack]
Take the tablet by mouth as directed
Rx#: 121836-NYM
Doctor:
Start: 07/12/19
Exp: 07/18/19
methylPFIEDNISolone 4 MG Tab [ 21 count Pack]
Take the tablet by mouth as directed
Rx#: 122149-NYM
Doctor:
Start: 07/30/19
Exp: 08/05/19
Pharmacy Dispensings: 21 tab in 304 days
Pharmacy Dispensings: 21 tab in 286 days
Generated 05:11)2020 09:57 by
OGC
Bureau of Prisons DAN
Page 1 of 2
EFTA00073915
Complex: NYM--NEW YORK MCC
Inmate:
EPSTEIN, JEFFREY EDWARD
Begin Date: 07/06/2019
End Date: 05/11/2020
Reg #:
76318-054
Quarter:
???-????
Active Prescriptions
Omega 3 (Vascepa) 1 GM Capsule
Take two capsules (2 GM) twice daily by mouth with food
Rx#: 121885-NYM
Doctor:
Start: 07/17/19
Exp: 01/13/20
D/C: 08/10/19
Pharmacy Dispensings: 180 Cap in 299 days
Insulin Reg (10 ML) 100 UNITS/ML Inj
Inject regular insulin subcutaneously per sliding scale: twice daily "'pill line"' for 7 days —pill line—
Rx#: 122148-NYM
Doctor:
Start: 07/30/19
Exp: 08/06/19
D/C: 07/31/19
Pharmacy Dispensings: 0 ML in 286 days
Insulin Reg (10 ML) 100 UNITS/ML Inj
Inject regular insulin subcutaneously per sliding scale: each morning for 7 days "'pill line"' "'pill line*"
Rx#: 122160-NYM
Doctor:
Start: 07/31/19
Exp: 08/07/19
Pharmacy Dispensings: 0 ML in 285 days
Page 085 of 148
Withheld pursuant to exemption
(b)(6); (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 05/11/2020 09:57 by
OGC
Bureau of Prisons - DAN
Page 2 of 2
EFTA00073916
Bureau of Prisons
Health Services
Dental Health History Screen
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Facility: NYM
Encounter Date: 07/26/2019 07:54
Provider:
DDS
Unit:
H01
ASSESSMENTS:
Health Problems as of Dental Health History Encounter date: 07/26/2019 07:54
Health Problems
Health Problem
Status
Hyperlipidemia, unspecified
Current
HYPERTRIGLYCERIDEMIA
Sleep apnea
Current
Constipation, unspecified
Current
Low back pain
Current
Neuralgia and neuritis, unspecified
Current
No Diagnosis
Current
Injury, unspecified
Current
RIO self inflicted injuries.
Medical History as of Dental Health History Encounter date:
07/26/2019 07:54
Medical History:
Allergies:
Denied
Page 086 of 148
Seizures:
Denied
Withheld pursuant to exemption
Diabetes:
Denied
Cardiovascular:
Denied
(b)(6); (b)(7)(A); (b)(7)(C)
CVA:
of Ehefeeledom of Information and Privacy Act
Hypertension:
Denied
Respiratory:
Denied
Sickle Cell Anemia:
Denied
Carcinoma/Lymphoma:
Denied
HIV History:
When Tested:
2019
Test Result:
Negative
When Diagnosed AIDS:
Last CD4:
Comments:
Hepatitis:
Denied
Generated 07,26/2019 07:59 by
DDS
Bureau of Prisons NYM
Page 1 of 3
EFTA00073917
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Facility: NYM
Encounter Date: 07/26/2019 07:54
Provider:
DDS
Unit:
H01
Other Infectious Diseases:
Syphilis:
Syphilis Last Treatment:
Genital Warts:
Chlamydia:
Gonorrhea:
Herpes:
Chicken Pox:
Other:
No
N/A
No
Yes
No
No
Yes
No
Comments: Chiamydia in 2015. treated
Chicken pox in childhood
Other Health Issues:
Other Medical Conditions And Treatment:sleep apnea
Current Medical Conditions:
Other Current Treatments:
Pregnant: N A
Dental Observations as of Dental Health History EncouRglecRARO/R/2019 07:54
Alcohol:
Methamphetamine:
Tobacco products:
Other drugs:
Sensitive teeth:
Bleeding gums:
Food impaction:
Pain around ear:
Toothache:
Wear partial dentures:
Unusual sounds while eating:
Snoring:
Blisters on lips or mouth:
Clenching or grinding:
Swelling or lumps in mouth throat:
Burning tongue:
Bad breath:
HiStinWVithheld pursuant to exemption
No
No
(b)(6) ; (b)(7)(A): (b)(7)(C)
of the Freedotm of Information and Privacy Act
No
No
Yes
Yes
No
No
No
No
Yes
No
Yes
No
No
No
Decayed teeth:
No
Loose teeth:
No
Wear dentures:
No
None:
No
Comments:
Generated 07,26 20 t 9 07:59 by
ODS
Bureau of Prisons NYM
Page 2 of 3
EFTA00073918
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Facility: NYM
Encounter Date: 07/2672019 07:54
Provider:
DDS
Unit:
H01
Cardiac Condition Requiring Prophylaxis: No
Prosthetic joint(s):
No
Radiation history of head or neck:
No
Excessive bleeding:
No
Bisphosphonates:
No
Comments:
Medications as of Dental Health History Encounter date:
07/26/2019 07:54
Medications:
Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth twice daily for 30 days
Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by mouth with food
OTCs: Listing of all known OTCs this inmate is currently taking.
Instructed inmate how to obtain medical, dental, and mental health care.
Copay Required:No
Cosign Required: No
Telephone/Verbal Order: No
Completed by
DDS on 07726:2019 07:59.
rage 088 of 148
Withheld pursuant to exemption
(b)(6); (b)(7)(A): (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07,26/2019 07:59 by
DDS
Bureau of Prisons NYM
Page 3 of 3
EFTA00073919
Bureau of Prisons
Health Services
Dental A&O Exam
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex: M
Race: WHITE
Encounter Date: 07/26,2019 07:47
Provider:
Reg #:
76318-054
Facility:
NYM
DDS
Unit:
H01
Reviewed Health Status:
Yes
Occlusion:
Class I
Oral Hygiene: Fair
CPITN:
3
2
3
3
2
3
Hard and soft tissue examination performed and documented on BP618 form: Yes
Head & Neck/Soft Tissue within normal limits?
No
Comments:
moderate to advanced upper posterior gingival recession
Decayed:
Missing:
Filled:
0
14
Comments:
Lower anterior crowding
Approved for hygiene appointment and radiographs:
Yes
Instructed inmate how to obtain routine and emergendie4e089 01O08 Oral hygiene instructions given:
Yes
Dental A&O Screening Exam findings entered onActhtelltilDttrSIW0UREeXeDfcAlArRD by
DOS on
0726/2019 07:47.
(b)(6). (b)(7)(A), (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07,262019 08:00 by
DDS
Bureau of Prisons NYM
Page 1 of 1
EFTA00073920
Bureau of Prisons
Health Services
Dental Soap/Admin Encounter
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Encounter Date: 07/18/2019 13:48
Provider:
Reg #:
76318-054
M
Race: WHITE
Facility:
NYM
Dental Asst
Unit:
Z05
Screening encounter at Dental Clinic.
Reason Not Done: Unavailable
Comments: Patient has had several call outs for his Dental A & O screening but has not been escorted to the dental clinic.
Cosign Required: No
Completed by
Dental Asst on 07/19/2019 13:49.
Page 090 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07/19/2019 13:49 by
Dental
Bureau of Prisons NYM
Page 1 of 1
EFTA00073921
Bureau of Prisons
-SENSITIVE BUT UNCLASSIFIED**
Psychology Services
Clinical Intervention - Clinical Contact
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
M
Facility: NYM
Date:
08/08/2019 10:02
Provider:
PhD/Chief
Reg #:
76318-054
Unit Team: 5
Focus of Session
Inmate Epstein was seen today for a follow-up session in SHU.
Subjective/Objective Presentation
Inmate Epstein stated he is feeling okay and has been eating his meals. He reported his sleep as "fair" and would like
to go the general population. He denied any mental health symptoms at this time and denied any feelings of depression
and/or anxiety. Inmate Epstein denied any suicidal ideation, intention, or plan. He currently has a cellmate and appears
to interact with him. Inmate Epstein continues to spend his days and evening with his attorney's in the attorney
conference room. He told this writer he received his PAC number to make phone calls. Inmate Epstein indicated he
has only had a couple of phone calls over the speaker phone and wondered "if that counted" as his monthly phone
contact. He also reported he his missing some books he was reading in the suicide watch area prior to returning to the
SHU.
Other than complaints about the prison and concerns regarding his housing, he had no mental health concerns today.
He did not appear to be in any distress and the SHU Staff have not reported any unusual behaviors on his part.
Intervention(s)
Inmate EPSTEIN was provided with brief supportive interventions and psychoeducation regarding additional coping
strategies. Inmate EPSTEIN was receptive to these interventions
rage 091 of 148
Progress/Plan
Inmate EPSTEIN was educated about both routifiglilOienteetytM
eat ig for contacting Psychology staff. He was
reminded of the self-help books and audiotapes avaif~
Ate
s
g§fejogy department. There appears to be no
need for follow up at this time. He will be seen in weekly rtjOirn
itnd ?n6ritfily for SHU reviews.
of the Freedom of Information and Privacy Act
Completed by
PhD/Chief Psychologist on 08/08/2019 10:09
Generated 0810812019 10:09 by
PhD/Chief
Bureau of Prisons NYM
Page 1 of 1
EFTA00073922
Bureau of Prisons
Psychology Services
Suicide Risk Assessment
"SENSITIVE BUT UNCLASSIFIED'.
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex: M
Facilit : NYM
Date:
08/01/2019 13:29
Provider:
PsyD
Reg #:
76318-054
Unit Team: 5
Type of Housing:
SHU- Administrative Segregation
Cell Accommodation: Double-Cell
FINDINGS
This assessment and the resulting recommendations are based on the following sources of information:
Clinical Interview. Medical Record. Psychology Data System, Sentry
R ea sQ0.10.LEteterral
& D staff reported to this writer this morning at about 8:30 AM on 8/01/19 that yesterday when Mr. Epstein was
brought back from court the US Marshals asked him to sign a form that noted Mr. Epstein has "suicidal tendencies." Mr.
Epstein was seen for a Suicide Risk Assessment at about 1:00 PM on 8101/19 in Attorney Conference.
This note is being entered at about 4:20 PM on 8/01/19.
Mental Health History
According to a Suicide Risk Assessment dated 7/09/19 by Dr.
"Inmate Epstein denied any history of mental
health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present
with psychotropic medication. He also denied any acute mental health symptoms at this time."
Self-Harm History
Pag
of 148
According to a Suicide Risk Assessment dated 7/09/19 by Dr.
, "Inmate Epstein denied any past or present
suicidal ideation, intention or plan. He denied eAtitbh§lnitoPt**josettfatPtiliftmpts or self-injurious behavior in the
past."
(b)(6), (b)(7)(A), (b)(7)(C)
According to this writer's Suicide
i
Riskpa,Pgibig adMiadidr;144 WM( C his time if he had placed the string
around his neck or if someone else di
Current Problem
& D staff reported to this writer this morning at about 8:30 AM on 8/01/19 that yesterday when Mr. Epstein was
brought back from court the US Marshals asked him to sign a form that noted Mr. Epstein has "suicidal tendencies."
This is likely due to the incident on 7/23/19, but as a precaution another Suicide Risk Assessment was conducted.
Mr. Epstein seemed surprised that there was a form noting suicidal tendencies. He denied stating he was suicidal.
He said he saw the DHO today and he said his incident report for the marks on his neck was expunged. He stated even
though he has his cpap machine now, he said his cellmate talks at night and he stated this keeps him up. This writer
offered to talk to the SHU Lt. to have him housed with a different cellmate. but he stated he wants to give it 3 to 4 days
to see if he wants a different cellmate. He complained about the noise in SHU.
Current Mental Status
Level of Consciousness:
Alert and Oriented
Psychomotor Activity:
Normal
General Appearance: Normal
Behavior: Cooperative
Mood: Appropriate to Content
Thought Process: Goal Directed
Thought Content:
Normal
Current Mental Status: He exhibited a neutral mood with a mildly restricted range of affect. His speech was logical and
Generated 08101t2019 16:21 by Imeri, Darlene PsyD
Bureau of Prisons NYM
Page 1 of 3
EFTA00073923
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex: M
Facilit : NYM
Date:
08/01/2019 13:29
Provider:
PsyD
Reg #:
76318-054
Unit Team: 5
coherent. with no loosening of associations or tangential, circumstantial or irrelevant speech. Auditory and visual
hallucinations were denied, and delusions were not elicited. He did not engage in any bizarre or inappropriate behavior. He
denied current suicidal or self harm ideation and he agreed to immediately tell staff if he starts to have suicidal or self harm
thoughts. He was future oriented. He does not appear to be an immediate danger to self. He denied thoughts of hurting
others and he agreed to tell staff if he has these thoughts.
RISK AND PROTECTIVE FACTORS ASSESSED:
This writer screened the inmate for a variety of empirically validated factors commonly associated with risk for self-harm and
suicide.
The following STATIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related
behaviors: High Profile Crime, Lack of family connections, Sex offender status
The following DYNAMIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related
behaviors: Current physical pain. Sleep problems
The following PROTECTIVE factors were assessed to be present and may decrease the inmate's risk of suicide:Able to identify
reasons to live, Denial of suicidal ideation/intention/plans, Future orientation, Religious beliefs against suicide, Supportive family
relationships. View of death as negative, Willingness to engage in treatment
Risk Factors: He was found by staff in his cell in SHU on 7/23/19 with a string loosely tied around his neck, which Mr. Epstein
stated he did not remember anything about. It is still unclear at this time if Mr. Epstein had placed the string around his own
neck or if someone else did. He has a high profile sex offense case. He stated his lower back hurts and he stated Medical is
aware of this. He stated he has difficulty sleeping even with his cpap machine because he stated his cellmate talks at night.
Protective Factors: He denied current suicidal or self harm thoughts and agreed to tell staff if he starts to have these thoughts.
He had denied a history of self harm and suicide attempts. He had denied a family history of suicidal and self harm attempts. He
had denied having any chronic medical conditions. He denied leVPQrStIM. He had denied a history of childhood abuse. He
denied fearing for his safety at this time. He denied MiNiwsigassiqg pigtails" He stated he lives for and plans to finish this
case and to go back to his normal life. He said his friends and Lawyers are erhotionally supportive. He said he is Jewish and
he said in his religion suicide is against the religion.
(b)(6): (b)(7)(A) ; (b)(7)(c)
Overall, his current protective factors overatitlibignesIdetattatinforroatiOaMyl Priwataitently psychologically stable. He denied
feeling hopeless. He is reporting positive future plans and reasons to live for. He said he has social supports in the community
and his Lawyers visit him often. He denied any current suicidal or self harm ideation, intention or plan. Suicide Watch is not
indicated at this time.
DIAGNOSIS-
No Diagnosis. No Dx - Current
CONCLUSIONS
The Overall Acute Suicide Risk for this Inmate is:
Low
Overall Chronic Suicide Risk for this Inmate is:
Absent
RECOMMENDATIONS
1. Suicide Watch is not indicated at this time.
2. Supportive and educative interventions were provided.
3. He was educated about both routine and emergency procedures for contacting Psychology staff.
4. He will be seen in follow up by Psychology next week to monitor his mental status and to provide further
intervention if needed.
5. In the meantime, he was encouraged to self-refer to Psychology if needed to which he agreed and seems capable of doing.
6. If he remains in SHU. he will be seen by Psychology in SHU Rounds and in SHU Reviews.
Suicide Watch:
A suicide watch is not warranted at this time
Generated 08/01/2019 16:21 by
PsyD
Bureau of Prisons - NYM
Page 2 of 3
EFTA00073924
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex: M
Facilit : NYM
Date:
08/01/2019 13:29
Provider:
PsyD
Reg #:
76318-054
Unit Team: 5
Completed by
PsyD on 08/01/2019 16:21
Page 094 of 148
Withheld pursuant to exemption
(b)(6) (b)(7)(A): (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 08/01/2019 16:21 by
PsyD
Bureau of Prisons NYM
Page 3 of 3
EFTA00073925
Bureau of Prisons
-SENSITIVE BUT UNCLASSIFIED. *
Psychology Services
Clinical Intervention - Clinical Contact
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01.20/1953
Sex:
M
Facility: NYM
Date:
07/31/2019 10:35
Provider:
BsyCi/DAPC
Reg #:
76318-054
Unit Team: 5
Focus of Session
Mr. EPSTEIN was seen today by this writer for a follow up appointment after he was removed from Psychological
Observation yesterday.
Subjective/Objective Presentation
Mr. EPSTEIN presented in a pleasant mood and reported he is generally doing well. He stated, "I could be better." but
acknowledged he is doing as well as can be expected given his circumstances. He reported he is going to court today
for a status hearing. He stated he generally slept well last night and is readjusting to being placed back in SHU. He
reported getting along well with his cell mate. He was informed of appropriate procedures for contacting Psychology
staff while he is in SHU, if needed.
Current Mental Status: Mr. EPSTEIN was alert and oriented, He was polite. calm, and cooperative in demeanor. He
exhibited a neutral affect with appropriate range. Eye contact and hygiene were appropriate. He spoke with normal rate.
tone, and volume. His thoughts were organized and coherent, with no loosening of associations or tangential,
circumstantial, or irrelevant content. There was no evidence of perceptual disturbance. delusional ideation, or a formal
thought disorder. He did not engage in any bizarre or inappropriate behavior. He noted having normal sleeping and
eating habits. Mr. EPSTEIN explicitly denied recent and current suicidal ideation. planning, and intent. He was future-
oriented and expressed a commitment to life and safety, agreeing to contact staff immediately should he experience
suicidal ideation or psychological distress. He also denied tlpgfl89(liaQging others.
Intervention(s)
Withheld pursuant to exemption
Supportive interventions and cognitive behavioral therapeutic techniques were utilized. Mr. EPSTEIN was receptive to
all interventions.
(b)(6); (b)(7)(A); (b)(7)(C)
RtMeaSinan
of the Freedom of Information and Privacy Act
Mr. EPSTEIN was educated about both routine and emergency procedures for contacting psychology. There appears to
be no need for follow-up at this time and he expressed willingness to self refer to psychology staff if needed. He will
continue to be seen during routine SHU rounds and SHU reviews while he is housed in SHU. He was encouraged to
reach out for PRN services should he experience any psychological distress.
Completed by
PsyD/DAPC on 07/31/2019 10:56
Generated 07/31/2019 10:56 by
PsyD(DAPC
Bureau of Prisons NYM
Page 1 ol 1
EFTA00073926
Bureau of Prisons
-SENSITIVE BUT UNCLASSIFIED-
Psychology Services
Clinical Intervention - Clinical Contact
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
M
Facility: NYM
Date:
07130(2019 12:01
Provider:
PsyD
Reg #:
76318-054
Unit Team: 5
Focus of Session
He was seen by writer while he was on Psych Observation.
Subjective/Objective Presentation
He stated he hasn't slept well at MCC-NY because he hasn't had his cpap machine. He stated it is here and he will be
able to start using it tonight. He discussed how he does not think he will able to sleep in SHU and how he does not like
SHU because of the noise. He discussed issues on not getting some medication with Medical today.
The "Eating/Shower Chart" indicated yesterday he ate breakfast and dinner, drank liquids, and took a shower when
offered and so far today it noted he ate breakfast and drank liquids. The Psych Observation Log noted he slept, drank
water, went to legal, and talked to an Inmate Companion about investments.
Current Mental Status: He exhibited a neutral mood with a full range of affect. His speech was logical and coherent, with
no loosening of associations or tangential, circumstantial or irrelevant speech. Auditory and visual hallucinations were
denied, and delusions were not elicited. He did not engage in any bizarre or inappropriate behavior. There was no
indication of disturbed thought process or content. Intellectual ability appeared to be above average. Personal hygiene
was adequate. He denied current suicidal or self harm ideation and he agreed to immediately tell staff if he starts to
have suicidal or self harm thoughts. He was future oriented. He does not appear to be an immediate danger to self. He
denied thoughts of hurting others and he agreed to tell stafffitalge 088 tifebit3thoughts.
Intervention(s)
Withheld pursuant to exemption
Supportive and educative interventions were provided. When asked about the Turning Point handouts for coping in
SHU, he stated he already knows these strategies beb)(13)blb)MAftie(bk70(gtts and had tried them when he was in SHU
the last time. He stated with the noise in SHU, he said the strategies will not work. He was encouraged to try them.
Progress/Plan
of the Freedom of Information and Privacy Act
The Chief Psychologist was consulted. Psych Observation will be discontinued. Mr. Epstein was educated about both
routine and emergency procedures for contacting Psychology staff. He will be seen in follow up by Psychology
tomorrow to monitor his mental status and to provide further intervention if needed and he was informed that he will be
seen by Psychology tomorrow. In the meantime. he was encouraged to self-refer to Psychology if needed to which he
agreed and seems capable of doing. If he remains in SHU, he will be seen by Psychology in SHU Rounds and in SHU
Reviews. The SHU Lt. was informed that Mr. Epstein needs to be housed with an appropriate cellmate.
Completed by
PsyD on 07/30/2019 13:54
Generated 07)30,2019 13:54 by
PsyD
Bureau of Prisons NYM
Page I of 1
EFTA00073927
Bureau of Prisons
"SENSITIVE BUT UNCLASSIFIED-
Psychology Services
Institution Disciplinary Process Report
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01)2011953
Sex:
M
Facility: NYM
Date:
07/30/2019 12:01
Provider:
PsyD
Reg #:
76318-054
Unit Team: 5
Reason for Referral and Identifying Information
Inmate Epstein was referred by Unit Manager
for an evaluation of competency to proceed with the disciplinary
process for actions resulting in an incident report. On 7/23/19, inmate Epstein was charged with code 228 (Tattooing or
Self-Mutilation). These infractions were assigned incident report number 3282555.
Background Information
According to a Suicide Risk Assessment dated 7/09/19 by Dr.
"Inmate Epstein denied any history of mental
health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present
with psychotropic medication. He also denied any acute mental health symptoms at this time."
According to a Suicide Risk Assessment dated 7/09/19 by Dr.
"Inmate Epstein denied any past or present
suicidal ideation. intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the
past."
According to this writer's Suicide Risk Assessment dated 7/23/19, "It is unclear at this time if he had placed the string
around his neck or if someone else did."
Clinical Interview and Mental Status Exam
Inmate Epstein still does not remember how he obtained the marks around his neck.
Page 097 of 148
Current Mental Status: He exhibited a neutral momitAigi 4.,tsfitrii.
b
Rprot egg
speech was logical and coherent, with
l
no loosening of associations or tangential. circumstantial
irrelevant speec . uditory and visual hallucinations were
denied, and delusions were not elicited. He did not eibogp terx,1041.ErypqMappropriate behavior. There was no
indication of disturbed thought process or content. Intellectual ability appeared to be above average. Personal hygiene
was adequate. He denied current suicditer&Sdamrofdatatalatiod bedierigactytAtrinmediately tell staff if he starts to
have suicidal or self harm thoughts. He was future oriented. He does not appear to be an immediate danger to self. He
denied thoughts of hurting others and he agreed to tell staff if he has these thoughts.
Clinical Impression
According to his last Diagnostic and Care Level Formulation Note dated 7/09/19 by Dr.
"No Diagnosis, No Dx -
Current."
Findings
The determination of whether an inmate is competent to proceed with the disciplinary process is based on a clinical
assessment of the inmate's (1) ability to understand the nature of the proceedings, and (2) their ability to assist in their
own defense. Depending on the outcome of the assessment. one of three findings can be made: (1) the inmate is
COMPETENT to proceed with the disciplinary process: (2) the inmate is NOT PRESENTLY COMPETENT but could be
restored to competence with treatment: or (3) the inmate is NOT COMPETENT and is unlikely to become competent.
Recommendations Regarding Sanctions
In the case of inmate Epstein. after a review of available psychological and psychiatric records as well as information
pertaining to the offense conduct, it is determined that this inmate is:
(X) COMPETENT to proceed with the disciplinary process.
( ) NOT PRESENTLY COMPETENT, but could become competent with treatment; it is recommended that the inmate for
an updated competency assessment in 30 days.
( ) NOT COMPETENT and not likely to become competent.
Generated 07130/2019 12:33 by
PsyD
Bureau of Prisons NYM
Page 1 of 2
EFTA00073928
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
M
Facility: NYM
Date:
07/30/2019 12:01
Provider:
Imeri, Darlene PsyD
Reg #:
76318-054
Unit Team: 5
Completed by
PsyD on 07/30/2019 12:33
Page 098 of 148
Withheld pursuant to exemption
(b)(6) (b)(7)(A): (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07/30,2019 12:33 by
PsyD
Bureau of Prisons NYM
Page 2 of 2
EFTA00073929
Bureau of Prisons
Psychology Services
General Administrative Note
**SENSITIVE BUT UNCLASSIFIED**
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
M
Facility: NYM
Date:
07/30/2019 12:01
Provider:
PsyD
Reg #:
76318-054
Unit Team: 5
Comments
Psych Observation Discontinuation Note:
Please see "Clinical Contact" dated today.
Completed by
PsyD on 07/30/2019 12:33
Page 099 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07/30/2019 12:33 by
PsyD
Bureau of Prisons - NYM
Page 1 of 1
EFTA00073930
Bureau of Prisons
-SENSITIVE BUT UNCLASSIFIED"
Psychology Services
Clinical Intervention - Clinical Contact
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01)201953
Sex:
M
Facility: NYM
Date:
07129/2019 10:01
Provider:
PhD/Chief
Reg #:
76318-054
Unit Team: 5
Focus of Session
Inmate Epstein was seen while on psychological observation today in the hospital area.
Subjective/Objective Presentation
Same presentation today, but he said he thinks his memory for the incident (injury to his neck) may be impaired
because of his sleep apnea. He is supposed to get his CPAP machine today. He is aware he will be returning to SHU,
but said he is feeling unwell due to his inability to sleep and numbness in his arm. He requested to have one good night
of sleep with his CPAP and will return to SHU with a cellmate tomorrow. He then asked if he could remain down here
where it is "safe" for the entire week. I told him he can stay down one more night to receive his CPAP and a good
night's sleep, but that he would be returned to SHU tomorrow. It was explained that there is no mental health issues
precluding him from returning to SHU tomorrow and that we could not house him in the SW/Hospital area because he
felt safe or more comfortable for him. It was explained to him that he would be placed in a safe situation in the SHU.
According to his log book and eating/shower chart, he has been eating and drinking when not in his legal visits. He has
also been writing and attending his legal visits.
Intervention(s)
Inmate EPSTEIN was provided with brief supportive interventions and psychoeducation regarding additional coping
strategies. Inmate EPSTEIN was somewhat receptive to thvg isitmeoritipas, but appears more concerned about getting
his various needs in the prison (phone calls. recreation. housir% placeme-a concerns. etc.)
Progress/Plan
Withheld pursuant to exemption
He will remain on psychological observation today a9g
l.tiNiligc.t.R.,1 4U tomorrow. He will be seen by
psychology daily to assess his mental status and pskliblb§afttnefia.
of the Freedom of Information and Privacy Act
Completed by
PhD/Chief Psychologist on 07/29/2019 10:26
Generated 07)29,2019 10:26 by
Phathiel
Bureau of Prisons NYM
Page 1 of 1
EFTA00073931
Bureau of Prisons
-SENSITIVE BUT UNCLASSIFIED"
Psychology Services
Clinical Intervention - Clinical Contact
Inmate Name:
EPSTEIN. JEFFREY EDWARD
Date of Birth:
01)201953
Sex:
M
Facility: NYM
Date:
07/28/2019 08:33
Provider:
PsyD
Reg #:
76318-054
Unit Team: 5
Focus of Session
He was seen by writer while he was on Psych Observation.
Subjective/Objective PresentaisIn
The "Eating/Shower Chart" noted that yesterday he ate breakfast. He is not in the Psych Observation cell for about 12
hours per day because of being in Attorney Conference with his Attorneys, so the "Eating/Shower Chart" may not reflect
all of his meals. He stated he was served one meal in Attorney Conference yesterday. He stated he drinks a lot water
at night. The Psych Observation log noted he talked about life in general population and he slept.
Earlier he had complained that his right arm was numb and hanging. Nurse
from Medical had seen him for
this.
When this writer was interviewing him, he said his right arm still feels somewhat numb and he said he cannot make a fist
with that hand. He also said he has numbness on his neck. This writer notified Nurse
He stated last night when he flushed the toilet it kept flushing for 45 minutes. He stated he found it so aversive and
upsetting that he said he sat in the corner and held his ears. He said because of this he was agitated for hours and was
not able to sleep. The Lt. will be moving him to a different cell and he was informed of this. He stated the feeling he got
with the noise of the toilet was similar to when he was in SHtitgelikEtaid thigrmay have something on the Autism
spectrum. He said in the movie "Rain Man," the person with Autism had an aversion to noise. He stated he is also
really good with numbers.
Withheld pursuant to exemption
Current Mental Status: He exhibited a mildly anxious(Pai
MPS! affect. His speech was logical and
coherent, with no loosening of associa4irinehtgaiAttAli fikiffifinaw
rica
speech. Auditory and visual
hallucinations were denied. and delusions were not elicited. He did not engage in any bizarre or inappropriate behavior.
He denied current suicidal or self harm ideation and he agreed to immediately tell staff and Inmate Companions if he
starts to have suicidal or self harm thoughts. He was future oriented. He does not appear to be an immediate danger to
self. He denied thoughts of hurting others and he agreed to tell staff and Inmate Companions if he has these thoughts.
Interventions)
Supportive and educative interventions were again provided. He had not been given the Turning Point handouts
yesterday that were on his cell door, so they were handed to him by staff today.
Progress/Plan
He will remain on Psych Observation in an abundance of caution and pending housing arrangements to be made on
Monday. While on Psych Observation, he will be seen daily by Psychology.
Completed by
PsyD on 07/28/2019 09:24
Generated 07/28,2019 09:24 by
PsyD
Bureau of Prisons NYM
Page 1 ol 1
EFTA00073932
Bureau of Prisons
-SENSITIVE BUT UNCLASSIFIED-
Psychology Services
Clinical Intervention - Clinical Contact
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/201953
Sex:
M
Facility: NYM
Date:
07;27/2019 07:14
Provider:
PsyD
Reg #:
76318-054
Unit Team: 5
Focus of Session
He was seen by writer while he was on Psych Observation.
Subjective/Objective Presentation
The "Eating/Shower Chart" indicated yesterday he ate dinner, drank liquids, and took a shower when offered. The
Psych Observation Log noted he brushed his teeth, went to a Legal visit, talked about business and investing to an
Inmate Companion, ate. and slept.
When interviewed, he stated he still cannot remember what happened in SHU that caused the marks on his neck. He
stated that for the 5 days before that he had only slept about 30 minutes each night because of noise in SHU. He stated
he is anxious about going back to SHU because he stated he is going back to a place where he had gotten marks on his
neck and he does not know why it happened.
He said he has an appetite and is eating. He said he is waking up every 1 1/2 hours. He stated he feels dehydrated
because he is not drinking enough water because he stated he feels he is not given enough bathroom breaks while with
his Attorney. Medical was e-mailed with his complaint of feeling dehydrated. He said his Lawyers and friends are all
emotionally supportive.
Current Mental Status: He exhibited a neutral mood with a fFillgenljtaaffIllect. His speech was logical and coherent, with
no loosening of associations or tangential, circumstantial or irrelevant speech. Auditory and visual hallucinations were
denied, and delusions were not elicited. He did nWIntIgh€14f§tiA9ttifiRrettnaRiffieppropriate behavior. He denied current
suicidal or self harm ideation. He stated "I'm a cowaWl'attqa
hviimirckot like pain and even does not like when
he has to give blood. He agreed to immediately tell VAtflar1difeuV)ale t'65iVriions if he starts to have suicidal or self
harm thoughts. He was future orientedoillfiediermatnaeiRmrpAWilrimiglanger
to self. He denied thoughts of
hurting others and he agreed to tell staff and Inmate Companions if he has these thoughts.
Intervention(s)
Supportive and educative interventions were provided. Turning Points handouts on stress management, sleep, and
building a routine in SHU were placed on his cell door to be given to him when his food slot is opened. He stated he
wants it noted in his chart that he is being given a pamphlet on sleep, but that is not going to help because of the noise
in SHU that prevents him from sleeping.
Progress/Plan
He will remain on Psych Observation in an abundance of caution and pending housing arrangements to be made on
Monday. While on Psych Observation, he will be seen daily by Psychology.
Completed by
PsyD on 07/28/2019 09:19
Generated 07/28,2019 09:19 by
PsyD
Bureau of Prisons NYM
Page 1 of 1
EFTA00073933
Bureau of Prisons
Psychology Services
Clinical Intervention - Clinical Contact
**SENSITIVE BUT UNCLASSIFIED**
Inmate Name
Date of Birth:
Date:
EPSTEIN, JEFFREY EDWARD
01/20/1953
Sex:
07127/2019 07:14
Provider:
M
Facility: NYM
PsyD
Reg #:
76318-054
Unit Team: 5
Focus of Session
He was seen by writer while he was on Psych Observation.
Subjective/Objective Presentation
The "Eating/Shower Chart" indicated yesterday he ate dinner, drank liquids, and took a shower when offered. The
Psych Observation Log noted he brushed his teeth, went to a Legal visit, talked about business and investing to an
Inmate Companion, ate. an
When interviewed, he st
stated that for the 5 days b
he is anxious about going bac
neck and he does not know why
II cannot remember what happened in SHU that caused the marks on his neck. He
e had only slept about 30 minutes each night because of noise in SHU. He stated
because he stated he is going back to a place where he had gotten marks on his
He said he has an appetite and is eati
He sa
id
is waking up every 1 1/2 hours. He stated he feels dehydrated
because he is not drinking enough water bec
tated he feels he is not given enough bathroom breaks while with
his Attorney. Medical was e-mailed with his
t •f feeling dehydrated. He said his Lawyers and friends are all
emotionally supportive.
Current Mental Status: He exhibited a neutral mood
1O8Parn§t6of affect. His speech was logical and
coherent, with no loosening of associations or tangential
ial or irrelevant speech. Auditory and visual
hallucinations were denied, and delusions were fr4e4heifb
WicYliffin any bizarre or inappropriate behavior.
He denied current suicidal or self harm ideation. He Mg
-Ip added he does not like pain and even
does not like when he has to give blood.
e agreed:1'6nm
al"and Inmate Companions if he starts to
have suicidal or self harm thoughts. Htflik fygeop,sigpiAriA
II
be an immediate danger to self. He
denied thoughts of hurting others and he agreed to tell staff and Inmat= 0
1Qns if he has these thoughts.
Intervention(s)
Supportive and educative interventions were provided. He was given Turnin
douts on stress management,
sleep, and building a routine in SHU. He stated he wants it noted in his chart th
given a pamphlet on
sleep, but that is not going to help because of the noise in SHU that prevents him f rung
Progress/Plan
He will remain on Psych Observation in an abundance of caution and pending housing arr
be made on
Monday. While on Psych Observation, he will be seen daily by Psychology.
Completed by
PsyD on 07/27/2019 08:16
Generated 07/27/2019 08:16 by
PsyD
Bureau of Prisons NYM
Page 1 of 1
EFTA00073934
Bureau of Prisons
-SENSITIVE BUT UNCLASSIFIED-
Psychology Services
Clinical Intervention - Clinical Contact
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01)2011953
Sex:
M
Facility: NYM
Date:
07/27/2019 07:14
Provider:
PsyD
Reg #:
76318-054
Unit Team: 5
Focus of Session
He was seen by writer while he was on Psych Observation.
Subjective/Objective Presentatism
The "Eating/Shower Chart" indicated yesterday he ate dinner, drank liquids, and took a shower when offered. The
Psych Observation Log noted he brushed his teeth, went to a Legal visit, talked about business and investing to an
Inmate Companion, ate. an
When interviewed, he st
stated that for the 5 days b
he is anxious about going bac
neck and he does not know why
II cannot remember what happened in SHU that caused the marks on his neck. He
e had only slept about 30 minutes each night because of noise in SHU. He stated
because he stated he is going back to a place where he had gotten marks on his
He said he has an appetite and is eatiNr He sa
id
is waking up every 1 1/2 hours. He stated he feels dehydrated
because he is not drinking enough water bec
tated he feels he is not given enough bathroom breaks while with
his Attorney. Medical was e-mailed with his
t •f feeling dehydrated. He said his Lawyers and friends are all
emotionally supportive.
Current Mental Status: He exhibited a neutral mood
tellninpt8of affect. His speech was logical and
coherent, with no loosening of associations or tangential
ial or irrelevant speech. Auditory and visual
hallucinations were denied, and delusions were PIMA
WiliYilffin any bizarre or inappropriate behavior.
He denied current suicidal or self harm ideation. He atopi
-ce added he does not like pain and even
does not like when he has to give blood.
e agreedterm
a and Inmate Companions if he starts to
have suicidal or self harm thoughts. Fit* #448o siviA%rci
II
be an immediate danger to self. He
denied thoughts of hurting others and he agreed to tell staff and Inmat
s if he has these thoughts.
Intervention(s)
Supportive and educative interventions were provided. He was given Turnin
douts on stress management,
sleep, and building a routine in SHU. He stated he wants it noted in his chart th
given a pamphlet on
sleep, but that is not going to help because of the noise in SHU that prevents him f ring
Progress/Plan
He will remain on Psych Observation in an abundance of caution and pending housing arr
be made on
Monday. While on Psych Observation, he will be seen daily by Psychology.
Completed by
PsyD on 07/27/2019 08:16
Generated 07/27;2019 08:16 by
PsyD
Bureau of Prisons NYM
Page 1 of 1
EFTA00073935
Bureau of Prisons
Health Services
See Amendment
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/27/2019 07:14
Facility:
NYM
Amendment made to this note by
PsyD on 07/28/2019 09:19.
Page 105 of 148
Withheld pursuant to exemption
(b)(6) (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Bureau of Prisons - NYM
EFTA00073936
Bureau of PriSonS
-SENSITIVE BUT UNCLASSIFIED**
Psychology Services
Clinical Intervention - Clinical Contact
Inmate Name:
EPSTEIN. JEFFREY EDWARD
Date of Birth:
01/201953
Sex:
M
Facility: NYM
Date:
07/26/2019 09:09
Provider:
PhD/Chief
Reg #:
76318-054
Unit Team: 5
Focus of Session
Inmate Epstein was seen while on psychological observation in our hospital area.
Subjective/Objective Presentation
Prior to this writer's contact with him, Inmate Epstein showered and dressed himself for his legal visit today. He was
smiling and did crack some jokes during the interview. He did elucidate some complaints and suggested being
disappointed with this writer as he wants "to trust me and for me to trust him." He stated he remains unhappy with legal
visiting procedures as he cannot go to the bathroom as frequently as he would like to since he has a "weak bladder."
Inmate Epstein also reported since coming to the psychological observation area, he has felt constipated and needs his
Colace. He had self-carry Colace in SHU, but since coming to the observation area, he has not had his medication.
This writer immediately notified medical and his pills were being processed during the interview. Inmate Epstein also
continues to complain about the conditions of SHU confinement (i.e.. feeling punished. smells. noise, and restrictions).
With regard to the events which lead to his initial placement on suicide watch, inmate Epstein stated he has no memory
of the event. He asked to speak with his old cellmate "Nick" to see if he can tell him what happened or see if his
memory could be triggered. He remarked. 1 am still trying to figure out how I got this (pointing to the scab around his
neck)." Inmate Epstein denies remembering harming himself and/or being harmed by his cellmate. He does not exhibit
symptoms of any cognitive disorder, seizure disorder, psychotic disorder, or dissociative disorder at this time or in the
past. Inmate Epstein denied any current suicidal ideation, irltigtiot0toplt48 He reported wanting to be alive to fight his
legal case and go back and live life. He referred to himself as "a coward" and "I'm Jewish." He said he is not the type
who likes pain or would ever attempt to harm hirrWO. held pursuant to exemption
While on psychological observation, inmate Epstein (PanleA)67dilkAPAPh9s. sleeping and interacting with the inmate
companions. He is in legal visiting the aiiifilitya8,9, yhyrtiewridsgrycgpight AVog book and eating/shower chart
reflect the same. He has been speaking to inmate companions about investment strategies and about prison
adjustment. Correctional Staff report during his legal visits. he is interacting with his attorney, animated. laughing. and
joking.
interventioks)
Inmate Epstein was provided with supportive and coping skills interventions today. He was receptive to them, but
mostly wanted to express his complaints about his current prison confinement status and needs. He wanted this writer
to address them.
Progress/Plan
Inmate Epstein will remain on psychological observation in an abundance of caution and pending housing arrangements
to be made on Monday. He continues to be vague and reports memory deficits regarding the events which lead to a
piece of sheet being placed loosely around his neck and marks with scabs around his neck.
Completed by
PhD/Chief Psychologist on 07/26/2019 10:05
Generated 07/26;2019 10:05 by
PhD/Chief
Bureau of Prisons NYM
Page 1 of 1
EFTA00073937
Bureau of Prisons
-SENSITIVE BUT UNCLASSIFIED-
Psychology Services
Clinical Intervention - Clinical Contact
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01)2011953
Sex:
M
Facility: NYM
Date:
07/25/2019 10:14
Provider:
PhD/Chief
Reg #:
76318-054
Unit Team: 5
Focus of Session
Inmate Epstein was seen by this writer this morning while on psychological observation in the hospital area of the
prison.
Subjective/Objective Presentation
Inmate Epstein was in good spirits today and engaged in reciprocal conversation with this writer this morning. He
smiled and remarked. "welcome back" when this writer arrived. He continues to assert he does not remember how he
received marks around his neck, remarking "I do not remember anything, maybe you can give me some cues." He
stated he just remembers going for a drink of water and the next thing he knew he woke up to the sound of his own
snoring. When this writer attempted to get a more detailed account from him, indicating that it would be rare to have
such impairments in memory as he does not suffer from an acute cognitive disorder, he smiled and said he understood
my position.
Inmate Epstein did reveal he is unhappy with his current confinement in Special Housing (SHU) as he considers it "a
punishment cell." He said he finds the restrictions up there unfair as he has not done anything wrong. Inmate Epstein
stated he feels it is dangerous in the SHU, he cannot sleep well up there due to noise from the other inmates, it smells,
and it is difficult for him to work on his legal case up there. He stated he has not received the phone calls he was
promised nor has he been able to receive recreation. It was explained to him that he spends the entire day in the
attorney conference room and it is likely that he has missedpl
tingsdelme staff members have attempted to give him
phone calls and recreation. Inmate Epstein also reported complaints about the attorney conference room, stating they
do not take him to the bathroom frequently enoupithheld pursuant to exemption
Inmate Epstein adamantly denied any suicidality at tAMPOri4,bailet) '1Wlevested in my case to fight it, I have a life
and I want to go back to living my life."46igt.%egjAyoiiig rusogogkittrgUpwa.
According to his log book, he has been eating, drinking, sleeping, and interacting with the inmate companions. He has
also been attending his daily legal visits.
Intervention(s)
Inmate EPSTEIN was provided with brief supportive interventions and psychoeducation regarding additional coping
strategies. Inmate EPSTEIN was mostly receptive to these interventions. He requested to be housed in general
population rather than the SHU and stated he wanted to remain on psychological observation due to his concerns with
being in the SHU.
Progress/Plan
In an abundance of caution, inmate Epstein will remain on psychological observation. He has yet to give an account of
how he sustained the marks around his neck, is not revealing much about his mental status. and there are concerns
about his adjustment at this time to being housed in the SHU. Inmate Epstein will be seen daily by psychology while on
psychological observation.
Completed by
PhD/Chief Psychologist on 07/25/2019 10:43
Generated 07;25,2019 10:43 by
PhDiChiel
Bureau of Prisons NYM
Page 1 of 1
EFTA00073938
Bureau of Prisons
Psychology Services
Post Suicide Watch Report
"SENSITIVE BUT UNCLASSIFIED—
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Date:
07/24/2019 09:23
Provider:
Reg It:
76318-054
M
Facility: NYM
Unit Team:
5
Ph.D.
Watch Start Date:
07)23/2019 01:40
Total Time on Watch:
31 hrs 5 minutes
Watch Conducted By:
Both inmates and staff
Current Mental Status
Watch Stop Date:
07'24,2019 08:45
Transfered to Medical Center:
No
Level of Consciousness:
Alert and Oriented
Psychomotor Activity:
Normal
General Appearance: Normal
Behavior: Cooperative
Mood: Appropriate to Content
Thought Process: Goal Directed
Thought Content:
Normal
Current Mental Status: Mr. EPSTEIN was alert and oriented. He was polite, calm. and cooperative in demeanor. He exhibited
a neutral affect with appropriate range. Eye contact and hygiene were appropriate. The inmate spoke with normal rate, tone,
and volume. His thoughts were organized and coherent, with no loosening of associations or tangential, circumstantial, or
irrelevant content. There was no evidence of perceptual disturbance, delusional ideation, or a formal thought disorder. He did
not engage in any bizarre or inappropriate behavior. He noted pagifigggiotiaoleeping and eating habits. Mr. EPSTEIN
explicitly denied recent and current suicidal ideation. planning, and intent. He was future-oriented and expressed a
commitment to life and safety. agreeing to contact stWiffhnftOttlarEOPIOniclnefOl4k95brience suicidal ideation or psychological
distress. He also denied thoughts of harming others.
(b)(6) ; (b)(7)(A); (b)(7)(C)
Risk Factors Assessed-
This writer screened the inmate for a variety0efrfrfifItititgiaeteteffiefee0erthowikstsociated with risk for self harm.
The following STATIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related
behaviors: High Profile Crime. Lack of family connections, Sex offender status
The following DYNAMIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related
behaviors: Current physical pain. Fear for own safety
The following PROTECTIVE factors were assessed to be present and may decrease the inmate's risk of suicide:Able to identify
reasons to live, Adequate problem solving skills, Denial of suicidal ideation/intention/plans, Future orientation, View of death as
negative, Willingness to engage in treatment
Risk Factors: Mr. EPSTEIN has a significant scar around his neck. which is now scabbing over. He reported swelling in this area
but denied experiencing any related pain. Mr. EPSTEIN continues to claim a lack of memory for the incident resulting in this scar.
The story he provided was vague, such that this writer challenged him a couple of times, but he insisted he was being honest about
his lapse in memory. The nature of the incident remain unclear. Mr. EPSTEIN is incarcerated for a very high profile crime with
media attention. He was recently denied bail. He also reported difficulty managing his time in the SHU. He reported being fearful
for his safety if he is to return to the cell with his previous cell mate.
Protective Factors: Mr. EPSTEIN adamantly denied current suicidal ideation or intent or a history of suicide attempts. He stated, "I
have no interest in killing myself." He explained. although his situation is "not perfect" due to his being incarcerated. he noted he
has "lots to do for [his] legal case." He described having a "wonderful life," to include interactions with "interesting people and
projects." He said "it would be crazy" to take his life. He furthered. "I would not do that to myself: He denied feelings of
hopelessness, although did report being "depressed" and "unhappy" about his current legal situation. He previously denied a
history of childhood abuse. He reported he is sleeping adequately now that he is no longer in the SHU. He appear future-oriented
as he endorsed an interest in being housed in general population.
Weighing of Risk and Protective Factors: Mr. EPSTEIN adamantly denied sucidality. However, in light of his vague self-report
regarding the incident which precipitated his placement on Suicide Watch, combined with his fear for his own safety, reported
Generated 07124/2019 12:09 by
Ph.D.
Bureau of Prisons NA/
Page 1 of 3
EFTA00073939
Inmate Name:
EPSTEIN. JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Facility: NYM
Unit Team:
5
Date:
07/24/2019 09:23
Provider:
Ph.D.
difficulty managing his time in the SHU. and the high profile nature of his alleged offense. Mr. EPSTEIN will be stepped down from
Suicide Watch to Psychological Observation.
Changes in Risk Factors Assessed
Upon a review of the log book, it was indicated Mr. EPSTEIN has been speaking to the inmate companions about
having previously taught mathematics and physics. He has been observed pacing the cell as well as sleeping. eating.
and drinking within normal limits.
Upon interview today. Mr. EPSTEIN requested he be provided a toothbrush as well as a shower. His requests were
made known to the lieutenants and he was provided a shower prior to attending his legal visit. This writer also provided
him a toothbrush, toothpaste, and hygiene products.
Asked about the alleged incident which transpired yesterday resulting in his placement on Suicide Watch. Mr. EPSTEIN
said he is frustrated he has been placed in a "punishment cell for no reason." Specifically, Mr. EPSTEIN was referring
to his placement in the SHU. Asked to recall the events surrounding the alleged incident. Mr. EPSTEIN said his cell
mate was "playing with a bed sheet" and he claimed he does not recall the events thereafter. He said he recalled eating
meat and drinking water and claimed the next event for which he has memory is his hearing himself snore and waking
up on a stretcher.
Mr. EPSTEIN claimed he does not recall himself or his cell mate tying a string or rope around his neck. He said he has
"been trying to remember" and "wracking his mind." Asked if he experienced any interpersonal issues with his cell
mate. Mr. EPSTEIN described his cell mate as "agitated" and claimed his cell mate called him a "pedophile" for the first
time yesterday. His cell mate was also reportedly reading a newspaper article about Mr. EPSTEIN, which bothered him
and it was something he believed to be "strange" for their to
lignonout him in his cell. Mr. EPSTEIN recalled
throwing away the newspaper photograph of himself by trump
i it and flushing it down the toilet. Asked if his cell
mate ever threatened to harm him, he denied this Withfiekercum antiiptaton
told the inmate companions yesterday
his cell mate tried to kill him, while also claiming no memory of the incident, Mr. EPSTEIN again said he did not recall
the incident and further stated. "I don't know if he put Iteifilecito(a)AelbX4)(EPSTEIN explained he had been
experiencing difficulty sleeping in his SHU cell due to his inmate peers banging on the cell door and window, but has not
been experiencing any other acute issu4 81SirrciORWIf. Information and Privacy Act
Reason for Removal from Watch
Mr. EPSTEIN stated, "I have no interest in killing myself." He explained although his situation is "not perfect" due to his
being incarcerated, he noted he has "lots to do for ihisl legal case." He described having a "wonderful life," to include
interactions with "interesting people and projects." He said "it would be crazy" to take his life. He furthered. "I would not
do that to myself." Mr. EPSTEIN did express a feeling of safety being housed on Psychological Observation rather than
in the SHU. He asked if he could remain on this status for a couple of days. he was advised his housing situation will be
re-evaluated on a day-to-day basis. He expressed a desire to be housed in general population rather than in the SHU
and asked if there were a "safer" unit for him to be housed in comparison to the one where he was initially placed. Mr.
EPSTEIN claimed there were many MS-13 gang members on the initial unit. He was advised he will be maintained on
Psychological Observation in the near future, but his long-term housing situation will be revisited. as it is not ideal for
one to remain in isolation on Psychological Observation for extended periods of time. Mr. EPSTEIN acknowledged this
information and thanked this writer for her explanation and time.
Diagnosis:
No Diagnosis, No Dx - Current
Conclusions
The Overall Acute Suicide Risk for this Inmate is:
Low
Overall Chronic Suicide Risk for this Inmate is:
Absent
Recommendations
1. Mr. EPSTEIN will be removed from Suicide Watch and stepped down to Psychological Observation.
2. While on Psychological Observation, he will be continuously observed by Inmate Companions.
3. While on Psychological Observation. he will be seen daily by Psychology.
4. Supportive and educative interventions were provided.
5. Mr. EPSTEIN was provided novels and a request was made for his legal paperwork to be provided to him on Psychological
Generated 07124/2019 12:09 by
Ph.D.
Bureau of Prisons
Page 2 of 3
EFTA00073940
Inmate Name:
EPSTEIN. JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
Date:
07/24/2019 09:23
Provider:
Reg #:
76318-054
M
Facility: NYM
Unit Team:
5
Ph.D.
Observation.
6. This writer contacted the Pharmacy to indicate Mr. EPSTEIN has not been receiving his medication used to alleviate his
constipation.
7. Mr. EPSTEIN attended a legal visit today. after having been provided a shower.
8. Mr. EPSTEIN was educated about both routine and emergency procedures for contacting psychology.
9. The inmate was encouraged to reach out for PRN services should he experience any psychological distress.
Completed by
Ph.D. on 07/24/2019 12:09
Page 110 of 148
Withheld pursuant to exemption
(b)(6) (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07/24/2019 12:09 by
Ph.D.
Bureau of Prisons NYM
Page 3 of 3
EFTA00073941
Bureau of Prisons
Psychology Services
Suicide Risk Assessment
"SENSITIVE BUT UNCLASSIFIED'.
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex: M
Facilit : NYM
Date:
07/23/2019 10:09
Provider:
PsyD
Reg #:
76318-054
Unit Team: 5
Type of Housing:
SHU- Administrative Segregation
Cell Accommodation: Double-Cell
FINDINGS
This assessment and the resulting recommendations are based on the following sources of information:
Clinical Interview. Medical Record. Psychology Data System, Sentry
EteassaLtQLEtetertal
The On Call Psychologist. Dr.
had been contacted by the Operations Lt. at about 2 AM on 7/23/19 to inform her
that Mr. Epstein was being placed on Suicide Watch because he was found with a string around his neck. Mr. Epstein
was seen by this writer for a Suicide Risk Assessment at about 9:10 AM on 7/23/19.
This note is being entered at about 3:35 PM on 7/23/19.
Mental Health History
According to a Suicide Risk Assessment dated 7/09/19 by Dr.
"Inmate Epstein denied any history of mental
health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present
with psychotropic medication. He also denied any acute mental health symptoms at this time."
Self-Harm History
Page 111 of 148
vii.
According to a Suicide Risk Assessment dated 7/09/19 by Dr.
, "Inmate Epstein denied any past or present
suicidal ideation, intention or plan. He denied ev*VinicA
frY8Smpts or self-injurious behavior in the
past."
(b)(6) ; (b)(7)(A) ; (b)(7)(C)
Substance Abuse History
According to a Suicide Risk Assessm6gtttitkre tiA9691(401547.10ffirrihF4tAceOthin denied any alcohol or substance
abuse. He said it is well-known that he does not even drink alcohol."
Current Problem
Earlier this morning Mr. Epstein was found by SHU staff in his cell with a string loosely tied around his neck. It is
unclear at this time if Mr. Epstein had placed the string around his own neck.
When Mr. Epstein was asked by this writer how he ended up on Suicide Watch, he denied remembering. He stated he
got a drink of water last night in his cell and went back to bed. He said the next thing he remembered is hearing himself
snore. He said he wants to know why he is on Suicide Watch. He was informed that staff stated he was found in his
cell with a string on his neck. According to Medical records, he had been seen by Medical for this and had a rule out of
self inflicted injuries.
When this writer reviewed the Staff Suicide Watch Log. it noted that Mr. Epstein told the staff watching him that his
cellmate tried to kill him. which Mr. Epstein did not tell this writer when this writer had interviewed Mr. Epstein. This
writer was not able to ask Mr. Epstein about this. since Mr. Epstein was now in Legal. The Captain was notified about
this notation and the Captain stated they were already aware of this statement.
CstrientMental Status
Level of Consciousness:
Alert and Oriented
Psychomotor Activity:
Normal
General Appearance: Normal
Behavior: Cooperative
Mood: Appropriate to Content
Generated 07/23/2019 15:38 by
PsyD
Bureau of Prisons NYM
Page 1 of 3
EFTA00073942
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex: M
Facilit : NYM
Date:
07/23/2019 10:09
Provider:
PsyD
Reg #:
76318-054
Unit Team: 5
Thought Process: Goal Directed
Thought Content:
Normal
Current Mental Status: He exhibited a neutral mood with a full range of affect. His speech was logical and coherent, with no
loosening of associations or tangential. circumstantial or irrelevant speech. Auditory and visual hallucinations were denied.
and delusions were not elicited. He did not engage in any bizarre or inappropriate behavior. He denied current suicidal or self
harm ideation and he agreed to immediately tell staff if he starts to have suicidal or self harm thoughts. He was future
oriented. He does not appear to be an immediate danger to self. He denied thoughts of hurting others and he agreed to tell
staff if he has these thoughts.
RISK AND PROTECTIVE FACTORS ASSESSED:
This writer screened the inmate for a variety of empirically validated factors commonly associated with risk for self-harm and
suicide.
The following STATIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related
behaviors: High Profile Crime, Lack of family connections. Sex offender status
The following DYNAMIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related
behaviors: Current physical pain
The following PROTECTIVE factors were assessed to be present and may decrease the inmate's risk of suicide:Able to identify
reasons to live. Adequate problem solving skills. Denial of suicidal ideation/intention/plans, Future orientation, View of death as
negative. Willingness to engage in treatment
Risk Factors: He was found by staff in his cell in SHU with a string loosely tied around his neck, which Mr. Epstein stated he did
not remember anything about. It is unclear at this time if Mr. Epstein had placed the string around his own neck or if someone
else did. According to Medical, he had a circular line around the base of his neck, which he denied knowing how he obtained.
He stated his throat hurts which was reported to Medical. He 1PaligS tlibWrlili% sex offense case and recently was denied bail.
When asked if he has any friends or family that are motionallv sKortive. he stated he does not know what that means. When
nneio DUES nt to exemption
emotional supports were explained to him and then again asked
e as any tamiiy or friends that are emotionally supportive. he
was vague and said he has a lot of people.
(b)(6): (b)(7)(A); (b)(7)(C)
Protective Factors: He denied current suiciblbefealtIbirof
eadiRntreimAkiese thoughts. He denied a history of self
harm and suicide attempts. He denied a family history of suicidal and self harm attempts. He denied having any chronic
medical conditions. He denied feeling hopeless. He denied a history of childhood abuse. He denied fearing for his safety. He
denied feeling like a burden to anyone. He reported he is sleeping adequately. He stated he lives to have fun, to enjoy life, and
to learn. He said his future plans include fighting his case and going back to his normal life.
Whereas, he is denying suicidal and self harm thoughts and has a lot of protective factors, he is denying that he remembers
how he ended up on Suicide Watch and has marks encircling his neck. It is unclear at this time if he had placed the string
around his neck or if someone else did. He will remain on Suicide Watch for further observation and safekeeping.
DIAGNOSIS:
No Diagnosis, No Dx - Current
CONCLUSIONS
The Overall Acute Suicide Risk for this Inmate is:
Moderate
Overall Chronic Suicide Risk for this Inmate is:
Absent
RECOMMENDATIONS
1. Mr. Epstein will remain on Suicide Watch for further observation and safekeeping.
2. While on Suicide Watch, he will be continuously observed by Inmate Companions.
3. While on Suicide Watch, he will be seen daily by Psychology.
4. Supportive and educative interventions were provided.
5. Medical was informed that he reported his throat hurts.
Suicide Watch:
A suicide watch was initiated by non-clinical staff and continues to be warranted
Suicide Watch was initiated on: 07/23/2019 01:40
Generated 07/23/2019 15:38 by
PsyD
Bureau of Prisons NYM
Page 2 of 3
EFTA00073943
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex: M
Facilit : NYM
Date:
07/23/2019 10:09
Provider:
PsyD
Reg #:
76318-054
Unit Team: 5
Completed by
PsyD on 07/23/2019 15:38
Page 113 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07/23/2019 15:38 by
PsyD
Bureau of Prisons NYM
Page 3 of 3
EFTA00073944
Bureau of Prisons
Psychology Services
General Administrative Note
- SENSITIVE BUT UNCLASSIFIED**
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01;20,1953
Sex:
M
Facility: NYM
Date:
07;23/2019 07:56
Provider:
PhD/Chief
Reg #:
76318-054
Unit Team: 5
Comments
This On-Call Psychologist was contacted by the Operations Lt. at about 2 AM on 7/23/19 to inform Mr. Epstein was
being placed on Suicide Watch because he was found with a string loosely hanging around his neck. Mr. Epstein will be
seen today by the duty psychologist for a Suicide Risk Assessment.
Completed by
PhD/Chief Psychologist on 07/24/2019 07:59
Page 114 of 148
Withheld pursuant to exemption
(b)(6); (b)(7)(A): (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07/24/2019 07:59 by
PhD/Chief
Bureau of Prisons NYM
Page 1 of 1
EFTA00073945
Bureau of Prisons
Psychology Services
SHU Review
"SENSITIVE BUT UNCLASSIFIED"
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Facility NYM
Unit Team:
A&O
Date:
07/18/2019 07:21
Provider:
PhD Chef
Placed in SHU:
07/10/2019
Type:
SHU
Status:
ADMIN.DETENTION
Threat to Self:
Low
Basis of Review:
Inmate was interviewed
Adjustment:
Satisfactory, segregation
not detrimental
Mental Status:
No significant mental health issues.
Threat to Others:
Low
Comments
Monthly SHU Review Note
Inmate Epstein was meeting with his legal team today and has a court hearing. He was not able to be seen for a SHU
review. Another attempt to interview him for a SHU review will be done in the near future.
Completed by
PhD/Chief Psychologist on 07/18/2019 12:06
Page 115 of 148
Withheld pursuant to exemption
(b)(6); (b)(7)(A) (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07/1812019 12:06 by
PhD/Chief
Bureau of Prisons NYM
Page 1 of
1
EFTA00073946
Bureau of Prisons
-SENSITIVE BUT UNCLASSIFIED**
Psychology Services
Clinical Intervention - Clinical Contact
Inmate Name:
EPSTEIN. JEFFREY EDWARD
Date of Birth:
01)201953
Sex:
M
Facility: NYM
Date:
07116/2019 12:48
Provider:
PhD!Chief
Reg #:
76318-054
Unit Team: MO
Focus of Session
Inmate Epstein called for this writer in attorney conference today. The officer in attorney conference notified this writer
that he was asking to be seen.
Subjective/Objective Presentation
Inmate Epstein reported he has not received a spoon or soap in SHU. nor did he receive the phone calls that were
"promised to him." He told this writer we need to have mutual trust that his needs are met in the prison. This writer told
inmate Epstein that she would address his concerns. On the way out, a staff member told this writer she witnessed
inmate Epstein receive two phone calls from the Lt. Nonetheless, this writer informed the SHU lieutenant of his
concerns and he said he would ensure that he had soap, a spoon, and his initial SHU phone call. Inmate Epstein did
not have any psychological concerns today. He denied any mental health symptoms or suicidality. He has been eating
as best as he can and has requested a Kosher diet.
Intervention(a)
Inmate EPSTEIN was provided with brief supportive and psychoeducation regarding additional coping strategies. Inmate
EPSTEIN was receptive to these interventions. He continued with his legal visit.
Progress/Plan
Inmate EPSTEIN was educated about both routine and emergency procedures for contacting Psychology staff. He was
reminded of the self-help books and audiotapes available ttPagghlifeoP90ehology department. There appears to be no
need for follow up at this time. He will be seen in SHU for rounds and monthly SHU reviews.
Withheld pursuant to exemption
Completed by
PhD/Chief Psychologist on dia.){§)26WM5(b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07118/2019 13:05 by
PhD/Chief
Bureau of Prisons NYM
Page 1 of 1
EFTA00073947
Bureau of Prisons
-SENSITIVE BUT UNCLASSIFIED"
Psychology Services
Clinical Intervention - Clinical Contact
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01120,1953
Sex:
M
Facility: NYM
Date:
07111/2019 15:21
Provider:
PhD/Chief
Reg St:
76318-054
Unit Team: MO
Focus of Session
Inmate Epstein was seen for his psychological observation follow-up in attorney conference this afternoon.
Subie_ctive/Objective Presentation
Inmate Epstein reported he has been consulting with his attorney most of the day. He elucidated concerns about his
incarceration including not receiving his property yet in SHU, feeling cold in his cell, not receiving his Colace, not having
enough water in attorney conference. and a desire to recreate in SHU." Inmate Epstein was also upset about wearing
an orange jumpsuit and being treated like "a bad guy" when he did not do anything wrong in the prison. Custody and
security concerns were addressed with inmate Epstein including why he has to wear his orange jumpsuit (due to his
being housed in SHU). He requested that he be placed in a brown uniform during his legal visits. He was told his
concerns would be addressed in the SHU meeting.
Inmate Epstein stated he is not having any current problems with his cellmate and indicated he at bran cereal for
breakfast and took a shower yesterday. He did not sleep well last night. Inmate Epstein continues to deny any suicidal
ideation, intention or plan. He did not appear to be in any distress at this time.
Intervention(s)
Inmate EPSTEIN was provided with brief supportive interventions, CBT-based interventions, and psychoeducation
regarding additional coping strategies. Inmate EPSTEIN waoaraatitivef tfaese interventions.
Progress/Plan
......
Inmate EPSTEIN was educated about both rout/ lYg V
l
n@re
lEi
gie
tnrtt egrd
for contacting Psychology staff. He was
e
reminded of the self-help books and audiotapes avaiiBlialt%
Aye(gfr)6tiology department. He will be seen next
week after his bail hearing to assess his mental status 'and syc °logical sea /lily.
of the Freedom of Information and Privacy Act
Completed by
PhD/Chief Psychologist on 07/12/2019 07:51
Generated 07/12/2019 07:51 by
PhD/Chief
Bureau of Prisons NYM
Page 1 ol 1
EFTA00073948
Bureau of Prisons
Psychology Services
General Administrative Note
**SENSITIVE BUT UNCLASSIFIED**
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20r1953
Sex:
M
Facility: NYM
Date:
07;11/2019 14:28
Provider:
PsyD
Reg St:
76318-054
Unit Team: MO
Comments
This writer attempted to see Mr. Epstein in the morning and then again in the afternoon for a Psych Observation Follow
Up. but he was in Attorney Conference.
Completed by Imen Darlene PsyD on 07/11/2019 15:51
Page 118 of 148
Withheld pursuant to exemption
(b)(6) (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07/11/2019 15:51 by
PsyD
Bureau of Prisons NYM
Page 1 of 1
EFTA00073949
Bureau of Prisons
"SENSITIVE BUT UNCLASSIFIED-
Psychology Services
Clinical Intervention - Clinical Contact
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01)201953
Sex:
M
Facility: NYM
Date:
07;10,2019 08:38
Provider:
PhD/Chief
Reg #:
76318-054
Unit Team: MO
Focus of Session
Inmate Epstein was seen today for a psychological observation contact in the hospital area by this writer.
Subjective/Obj€ctive Presentation
Inmate Epstein appeared well and it was noted in his log book and eating/sleeping chart that he has been eating his
meals, sleeping, interacting with the inmate companions, and pacing in his cell. Today, he presented this writer with
numerous concerns and requests. He stated he does not want to be housed in the SHU because he is not comfortable
there: he wants to be single-celled if he goes to the SHU: he wants Colace. not the Ducolex he received from medical
yesterday; he wants to be able to walk around and go to recreation; he does not want to wear an orange uniform to his
legal visits because he is treated "like a punished inmate:" he wants a phone call before he leaves the psychological
observation area: he wants a shower and towel: he would like to be housed in the cadre (5S) unit; and would like his
property. paper. and a pen.
Inmate Epstein's concerns were addressed by this writer and it was explained to him he will not be single-celled or
placed in a housing unit for safety and security concerns. His medical concerns (constipation) were discussed with
health services as well as his desire to be placed on Colace. Inmate Epstein was provided a shower this morning.
Intervention(s)
Inmate Epstein was provided with supportive intervention aglco4i4 st yostrategies today. He was receptive to
interventions and was able to elucidate his various needs. Hand noPpresent with any acute psychopathology and
continues to deny any suicidal ideation. intentionAftiNglatki6iftrthigwdRoywii to his bail hearing on Monday but
stated he is aware that even if he gets bail, it will take at least two weeks to sort things out so he can leave the jail.
Progress/Plan
(b)(6), (b)(7)(A), (b)(7)(C)
Inmate Epstein is not in any psychologi
443F@€EOFIPiSfIRf2SrRf8
)3wdh°f7Pjfcgla@tat health symptoms or complaints.
and is denying any suicidality. He appears psychologically stable at this time and can be released from the
psychological observation area. Inmate Epstein will be housed in the 9S area with a cellmate. He will be seen again
tomorrow by psychology to evaluate his mental status and psychological stability.
Completed by
PhD/Chief Psychologist on 07/10/2019 09:09
Generated 07/10/2019 09:09 by
PhD/Chief
Bureau of Prisons NYM
Page I of I
EFTA00073950
Bureau of Prisons
-SENSITIVE BUT UNCLASSIFIED-
Psychology Services
Diagnostic and Care Level Formulation
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
0112011953
Sex:
M
Facility: NYM
Date:
07109(2019 10:13
Provider:
PhD/Chief
Reg #:
76318-054
Unit Team: A&O
Relevant Historical Information
Inmate Epstein is a 66-year-old Caucasian male, currently incarcerated on sex trafficking charges. He denied any
history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the
past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. Inmate
Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts
or self-injurious behavior in the past. Inmate Epstein denied any alcohol or substance abuse. He said it is well-known
that he does not even drink alcohol.
Presenting Problem/Symptom
Inmate Epstein was seen by this writer for suicide risk assessment today, 7/9/19 at 7:30 a.m. for precautionary reasons.
He returned from court yesterday evening. He did not mark any mental health items or symptoms on his Psychology
Questionnaire (PSIQ) when he entered the institution. Nonetheless. Inmate Epstein has various risk factors for
suicidality including a high profile case with media attention, sex offense/trafficking charges, pre-trial status, and he had
a court proceeding yesterday which could have given him bad news regarding his legal situation. Inmate Epstein
returned from court after duty hours yesterday evening and staff notified the on-call psychologist. Inmate Epstein was
placed on a precautionary psychological observation status until psychology could interview him this morning to conduct
a formal suicide risk assessment in order to determine whether he is currently at-risk for suicidality.
Diagnostic Formulation
Inmate Epstein has no history of mental health problems anPdSWetPoifelihtit suicidality at this time. He has never
received inpatient or outpatient mental health treWiNgorAyagg4AKANaof suicidality. Currently, he does not
exhibit any acute psychopathology, is currently psychologically stable and is in no psychological distress. As such, he is
being classified as a CC1-MH inmate at this time. CO%) AfhttiNje)iffigekytychan inmate who either has no identifiable
mental illness (Axis I "No Diagnosis") or is mildly ill and requires clinical intervention on an as-needed basis.
Care Level Formulation
of the Freedom of Information and Privacy Act
CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental
illness and demonstrates no need for regular mental health intervention.
Diagnosis:
No Diagnosis. No Dx - Current
Completed by
PhD/Chief Psychologist on 07/09/2019 10:40
Generated 07109,2019 10:40 by
PhD/Chief
Bureau of Prisons NYM
Page 1 of 1
EFTA00073951
Bureau of Prisons
Psychology Services
Diagnostic and Care Level Formulation
"SENSITIVE BUT UNCLASSIFIED**
Inmate Name
Date of Birth:
Date:
EPSTEIN, JEFFREY EDWARD
01/20/1953
Sex:
07109/201910:13
Provider:
M
Facility: NYM
PhD/Chief
Reg #:
76318-054
Unit Team: A&O
Relevant Historical Information
Inmate Epstein is a 66-year-old Caucasian male, currently incarcerated on sex trafficking charges. He denied any
history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the
past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. Inmate
Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts
or self-injurious behavior in th,past. Inmate Epstein denied any alcohol or substance abuse. He said it is well-known
that he does not even drink
Inmate Epstein was seen
health items or symptoms on h
Epstein has various risk factors
charges, pre-trial status, and he had
legal situation. Inmate Epstein return
psychologist. Inmate Epstein was placed on
interview him this morning to conduct a fo
suicidality.
Diagnostic Formulation
Inmate Epstein has no history of mental health proble
received inpatient or outpatient mental health tre
exhibit any acute psychopathology, is currently pt icittg c
being classified as a CC1-MH inmate at this time. WM:
mental illness (Axis I "No Diagnosis") or is mildly ill and requires
Care Level Formulation
of the Freedom of Information
.sk assessment today for precautionary reasons. He did not mark any mental
ology Questionnaire (PSIQ) when he entered the institution. Nonetheless, Inmate
y including a high profile case with media attention, sex offense/trafficking
proceeding yesterday which could have given him bad news regarding his
om courtier duty hours yesterday evening and staff notified the on-call
onary psychological observation status until psychology could
risk assessment to determine whether he is currently at-risk for
i felAbit suicidality at this time. He has never
gaahof suicidality. Currently, he does not
nd is in no psychological distress. As such, he is
(gan inmate who either has no identifiable
ention on an as-needed basis.
CARE1-MH is indicative of an inmate who shows no significant level of
illness and demonstrates no need for regular mental health intervention.
Diagnosis:
No Diagnosis. No Dx - Current
Completed by
PhD/Chief Psychologist on 07/09/2019 10:32
airment associated with a mental
Generated 07109,2019 10:32 by
PhOiChiel
Bureau of Prisons NYM
Page 1 ol 1
EFTA00073952
Bureau of Prisons
Psychology Services
Diagnostic and Care Level Formulation
**SENSITIVE BUT UNCLASSIFIED"
Inmate Name
Date of Birth:
Date:
EPSTEIN, JEFFREY EDWARD
01)201953
Sex:
07109/201910:13
Provider:
Facility: NYM
PhD/Chief
Reg #:
76318-054
Unit Team: MO
Relevant Historical Information
Inmate Epstein is a 66-year-old Caucasian male, currently incarcerated on sex trafficking charges. He denied any
history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the
past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. Inmate
Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts
or self-injurious behavior in th,past. Inmate Epstein denied any alcohol or substance abuse. He said it is well-known
that he does not even drink
Presenting Problem/
Inmate Epstein was seen
sk assessment today for precautionary reasons. He did not mark any mental
health items or symptoms on h
ology Questionnaire (PSIQ) when he entered the institution. Nonetheless, Inmate
Epstein has various risk factors
' y including a high profile case with media attention, sex offense/trafficking
charges, pre-trial status, and he had
proceeding yesterday which could have given him bad news regarding his
legal situation. Inmate Epstein return
om court
ter duty hours yesterday evening and staff notified the on-call
psychologist. Inmate Epstein was placed on
onary psychological observation status until psychology could
interview him this morning to conduct a for
risk assessment to determine whether he is currently at-risk for
suicidality.
Diagnostic Formulation
Inmate Epstein has no history of mental health proble
received inpatient or outpatient mental health tre
exhibit any acute psychopathology, is currently pt ictiog c
being classified as a CC1-MH inmate at this time. CMS):
mental illness (Axis I "No Diagnosis") or is mildly ill and requires
Care Level Formulation
of the Freedom of Information
CARE1-MH is indicative of an inmate who shows no significant level of
illness and demonstrates no need for regular mental health intervention.
Diagnosis:
No Diagnosis. No Dx - Current
Completed by
PhD/Chief Psychologist on 07/09/2019 10:32
12-ao9felikit suicidality at this time. He has never
gagiyisfiof suicidality. Currently. he does not
nd is in no psychological distress. As such, he is
Man inmate who either has no identifiable
ention on an as-needed basis.
airment associated with a mental
Generated 07/09/2019 10:32 by
PhD/Chief
Bureau of Prisons NYM
Page 1 of 1
EFTA00073953
Bureau of Prisons
Health Services
See Amendment
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/09/2019 10:13
Facility:
NYM
Amendment made to this note by
PhD/Chief Psychologist on 07/09/2019 10:40.
Page 123 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Bureau of Prisons NYM
EFTA00073954
Bureau of Prisons
Psychology Services
Suicide Risk Assessment
"SENSITIVE BUT UNCLASSIFIED'.
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex: M
Facilit : NYM
Unit Team: A&O
Date:
07/09/2019 08:41
Provider:
PhD/Chief Psychologist
Type of Housing:
Other Psychological Observation
Cell Accommodation: Single Cell
EltiifiNaS
This assessment and the resulting recommendations are based on the following sources of information:
Medical Record. Clinical Interview
Inmate Epstein was placed on psychological observation when he returned from court yesterday evening 7/8/19 for
precautionary reasons. He is not on a suicide watch at this time. He was seen this morning for a psychological observation
contact and suicide risk assessment this morning, 7/9/19. at 7:30 a.m. as it was determined he possessed some at-risk
factors for suicidality.
Reason for Referral
Inmate Epstein is being seen for suicide risk assessment today for precautionary reasons. Inmate Epstein has various
risk factors for suicidality at this time including a high profile case with media attention. sex offense/trafficking charges,
pre-trial status. and he had a court proceeding yesterday which could have given him bad news regarding his legal
situation. As such, this writer instructed IIII staff, as well as the Lieutenant's Office, to immediately notify the
psychology department when he returned from court. Inmate Epstein returned from court after duty hours and denied
suicidality. The aforementioned staff notified the on-call psychologist and inmate Epstein was placed on a precautionary
psychological observation status until psychology could intprekjievitaittlikanorning to conduct a suicide risk assessment.
Developmental History
Withheld pursuant to exemption
Inmate Epstein denied any history of being the victim and/or perpetrator or physical or sexual abuse.
Educational History/Cognitive Impairment
(b)(6) ; (b)(7)(A); (b)(7)(C)
Inmate Epstein reported he obtained V kigtetApiRf8a-affie,RtMollictfgefttoraduate classes in the area of
mathematics.
Arrest History_and_EXPerience olJacar_caration
Inmate Epstein reported he has served time in Palm Beach County jail on sex offense charges (soliciting prostitution) in
the past. He is now being charged with sex trafficking, on a federal level.
Mental Health History
Inmate Epstein denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein
denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health
symptoms at this time.
SatItUiblQnt
Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide
attempts or self-injurious behavior in the past.
Substance Abuse History
Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol.
Medical Concerns
Inmate Epstein denied any significant medical problems, other than a history of high triglycerides. He reported feeling
constipated at this time.
Current Problem
Inmate Epstein is currently on psychological observation due to his having multiple risk factors associated with
suicidality. He denies any suicidality at this time and has no mental health or suicide history. He is being seen for a
suicide risk assessment in an abundance of caution.
Current Mental Status
Generated 07/10/2019 09:20 by Miller, Elissa PhD/Chief
Bureau of Prisons - NYM
Page 1 of 3
EFTA00073955
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex: M
Facilit : NYM
Unit Team: A&O
Date:
07/09/2019 08:41
Provider:
PhD/Chief Psychologist
Level of Consciousness:
Alert and Oriented
Psychomotor Activity:
Normal
General Appearance: Normal
Behavior: Cooperative
Mood: Appropriate to Content
Thought Process: Goal Directed
Thought Content:
Normal
Inmate Epstein did not exhibit any acute psychopathology and exhibited a clear mental status.
Current Mental Status: Mr. EPSTEIN was alert and oriented. He was polite, calm. and cooperative in demeanor. He exhibited
a neutral affect with appropriate range. Eye contact and hygiene were appropriate. The inmate spoke with normal rate, tone,
and volume. His thoughts were organized and coherent, with no loosening of associations or tangential, circumstantial, or
irrelevant content. There was no evidence of perceptual disturbance. delusional ideation, or a formal thought disorder. He did
not engage in any bizarre or inappropriate behavior. He noted having normal sleeping and eating habits. Mr. EPSTEIN
explicitly denied recent and current suicidal ideation. planning. and intent. He was future-oriented and expressed a
commitment to life and safety, agreeing to contact staff immediately should he experience suicidal ideation.
RISK AND PROTECTIVE FACTORS ASSESSED:
This writer screened the inmate for a variety of empirically validated factors commonly associated with risk for self-harm and
suicide.
The following STATIC risk factors were assessed to be preserIbiawlimmitre inmate's risk for engaging in suicide related
behaviors: Sex offender status. Lack of family connections. High Profile Crime
Of the DYNAMIC risk factors assessed, none were Wiihttel;f4 NrwaArip. exemption
The following PROTECTIVE factors were assessed to tokeyppiymAyNtafc)twase the inmate's risk of suicide:Willingness to
engage in treatment, View of death as negative. Future orientation, Denial of suicidal ideation/intention/plans, Adequate problem
solving skills. Able to identify reasons to liGtthe Freedom of Information and Privacy Act
As noted above. Inmate Epstein is a 66-year-old Caucasian male. He has various risk factors for suicidality at this time
including a high profile case with extensive media attention, sex offense/trafficking charges, pre-trial status, and he had a court
proceeding yesterday which may have given him bad news regarding his legal situation. Inmate Epstein also informed this
writer that his only family at this time is his brother. with whom he does not have a close relationship with.
Despite these risk factors, inmate Epstein possesses a number of protective factors at this time. Inmate Epstein adamantly
denied any suicidal ideation, intention or plan. He was very future oriented and requested a phone call, to meet with his
attorney, to take a shower. and to brush his teeth. He was eating his cereal when this writer arrived and said "I have my paper
spoon here." He reported he is going to have a bail hearing on Monday and believes he is going to be released from jail.
Inmate Epstein reported he is a Banker and has a "big business" in the community and that "being alive is fun." He also
revealed he enjoys learning and teaching. He has confidence in his attorney and described him as "competent." Inmate
Epstein denied any mental health history or history of suicidality. He also reported none of his family members have mental
health histories. Inmate Epstein stated he is a mathematician and took post graduate classes in this area of study. Inmate
Epstein stated he has a support system in the community. including friends and other associates. Finally, inmate Epstein
demonstrated a good sense of humor and did not appear dysphoric, agitated or anxious. No acute psychopathology was noted.
Overall, inmate Epstein has numerous protective factors at this time that outweigh his risk factors for suicidality. He has a
positive outlook regarding his legal case. demonstrates no psychiatric symptoms, has no psychiatric or suicide history, and
verbalized a desire to be alive at this time and future orientation.
DIAGNOSIS:
No Diagnosis, No Dx - Current
Generated 07/10/2019 09:20 by
PhaChiet
Bureau of Prisons NYM
Page 2 of 3
EFTA00073956
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg 11:
76318-054
Date of Birth:
01/20/1953
Sex: M
Fa ilit : NYM
Unit Team: A&O
Date:
07/09/2019 08:41
Provider:
PhD/Chief Psychologist
CONCLUSIONS
The Overall Acute Suicide Risk for this Inmate is:
Low
Overall Chronic Suicide Risk for this Inmate is:
Absent
RECOMMENDATIONS
Inmate Epstein is currently on psychological observation pending suitable housing placement. In light of his current sex offense
charges and extensive media coverage on the television, he will need to be confined in a suitable housing unit. Inmate Epstein
will be seen daily while on psychological observation and will be seen for a psychological observation follow-up session once he
is released from observation. Inmate Epstein denied the need for psychological intervention, self-help materials, or follow-up.
He has been classified as a CC1-MH inmate at this time. CARE1-MH is indicative of an inmate who shows no significant level
of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention.
Suicide Watch:
A suicide watch is not warranted at this time
Completed by
PhD/Chief Psychologist on 07/10/2019 09:20
Page 126 of 148
Withheld pursuant to exemption
(b)(6) (b)(7)(A) (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07/10/2019 09:20 by
PhD/Chief
Bureau of Prisons - NYM
Page 3 of 3
EFTA00073957
Bureau of Prisons
Psychology Services
Suicide Risk Assessment
"SENSITIVE BUT UNCLASSIFIED'.
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex: M
Facilit : NYM
Unit Team: MO
Date:
07/09/2019 08:41
Provider:
PhD/Chief Psychologist
Type of Housing:
Other Psychological Observation
Cell Accommodation: Single Cell
FINDINGS
This assessment and the resulting recommendations are based on the following sources of information:
Clinical Interview, Medical Record
Inmate Epstein was placed on
chological observation when he returned from court yesterday evening 7/8/19 for
precautionary reasons. He i
a suicide watch at this time.
Reason for Referral
Inmate Epstein is being seen f
e risk assessment today for precautionary reasons. Inmate Epstein has various
risk factors for suicidality at thi
'
ing a high profile case with media attention, sex offense/trafficking charges.
pre-trial status, and he had a court
o
ing yesterday which could have given him bad news regarding his legal
situation. As such, this writer instruc
&D staff
s well as the Lieutenant's Office, to immediately notify the
psychology department when he returned fro
Inmate Epstein returned from court after duty hours and denied
suicidality. The aforementioned staff notifi
-call psychologist and inmate Epstein was placed on a precautionary
psychological observation status until psycholo
,terview him this morning to conduct a suicide risk assessment.
Developmental History
Inmate Epstein denied any history of being the victim
Ma?
physical or sexual abuse.
Educational History/Cognitive Impairment
Withheld
o exemption
Inmate Epstein reported he obtained his high scho%citgl4
drme graduate classes in the area of
mathematics.
Arrest History and Experience of
toMatheedom of Information
Inmate Epstein reported he has served time in Palm Beach County jail
apse charges (soliciting prostitution) in
the past. He is now being charged with sex trafficking, on a federal level.
Mental Health History
O
Inmate Epstein denied any history of mental health treatment, either on an inpat
tient basis. Inmate Epstein
denied any treatment in the past or present with psychotropic medication. He also d I
acute mental health
symptoms at this time.
Self-Harm History
Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever a
ging in any suicide
attempts or self-injurious behavior in the past.
Substance Abuse History
Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol.
Medical Canaeini
Inmate Epstein denied any significant medical problems, other than a history of high triglycerides. He reported feeling
constipated at this time.
Current Problem
Inmate Epstein is currently on psychological observation due to his having multiple risk factors associated with
suicidality. He denies any suicidality at this time and has no mental health or suicide history. He is being seen for a
suicide risk assessment in an abundance of caution.
Current Mental Status
Level of Consciousness:
Alert and Oriented
Generated 07/09/2019 10:36 by
PhD/Chief
Bureau of Prisons - NYM
Page 1 of 3
EFTA00073958
Inmate Name
Date of Birth:
Date:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
01/20/1953
Sex: M
Facilit : NYM
Unit Team: A&O
07/09/2019 08:41
Provider:
PhD/Chief Psychologist
Psychomotor Activity:
Normal
General Appearance: Normal
Behavior: Cooperative
Mood: Appropriate to Content
Thought Process: Goal Directed
Thought Content:
Normal
Inmate Epstein did not exhibit any acute psychopathology and exhibited a clear mental status.
Current Mental Status: Mr. EP
a neutral affect with appropri
and volume. His thoughts
irrelevant content. There
not engage in any bizarre or ina
explicitly denied recent and curre
commitment to life and safety, agree'
IN was alert and oriented. He was polite, calm, and cooperative in demeanor. He exhibited
e. Eye contact and hygiene were appropriate. The inmate spoke with normal rate, tone,
nized and coherent, with no loosening of associations or tangential. circumstantial. or
ce of perceptual disturbance, delusional ideation, or a formal thought disorder. He did
e behavior. He noted having normal sleeping and eating habits. Mr. EPSTEIN
eation, planning, and intent. He was future-oriented and expressed a
act staff immediately should he experience suicidal ideation.
RISK AND PROTECTIVE FACTORS
SSED•
This writer screened the inmate for a variety of
suicide.
The following STATIC risk factors were assessed t
behaviors: High Profile Crime, Lack of family connect
Of the DYNAMIC risk factors assessed, none were foun
validated factors commonly associated with risk for self-harm and
and increase the inmate's risk for engaging in suicide related
ender status
g of 148
The following PROTECTIVE factors were assessed \41.0
Ilse the inmate's risk of suicide:Able to identify
reasons to live. Adequate problem solving skills. Denial of suici.
ntion/plans. Future orientation, View of death as
negative. Willingness to engage in treatment
(b)(6): (
As noted above, Inmate Epstein is a 66-yeartotcrraddtaieAt trgolen
factors for suicidality at this time
including a high profile case with extensive media attention, sex offense/tr-
rges. pre-trial status. and he had a court
proceeding yesterday which may have given him bad news regarding his leg
Inmate Epstein also informed this
writer that his only family at this time is his brother, with whom he does not hav
Cl
ationship with.
Despite these risk factors, inmate Epstein possesses a number of protective factors atRii
Inmate Epstein adamantly
denied any suicidal ideation, intention or plan. He was very future oriented and requeste
call, to meet with his
attorney. to take a shower, and to brush his teeth. He was eating his cereal when this writ
d said "I have my paper
spoon here." He reported he is going to have a bail hearing on Monday and believes he is go g t
sed from jail.
Inmate Epstein reported he is a Banker and has a "big business" in the community and that "bei
fun." He also
revealed he enjoys learning and teaching. He has confidence in his attorney and described him as
mpetent." Inmate
Epstein denied any mental health history or history of suicidality. He also reported none of his family members have mental
health histories. Inmate Epstein stated he is a mathematician and took post graduate classes in this area of study. Inmate
Epstein stated he has a support system in the community, including friends and other associates. Finally. inmate Epstein
demonstrated a good sense of humor and did not appear dysphoric, agitated or anxious. No acute psychopathology was noted.
Overall, inmate Epstein has numerous protective factors at this time that outweigh his risk factors for suicidality. He has a
positive outlook regarding his legal case, demonstrates no psychiatric symptoms, has no psychiatric or suicide history, and
verbalized a desire to be alive at this time and future orientation.
DIAGNOSIS-
No Diagnosis. No Dx - Current
CONCLUSIONS
The Overall Acute Suicide Risk for this Inmate is:
Overall Chronic Suicide Risk for this Inmate is:
Low
Absent
Generated 07109i2019 10:36 by
PhaChiel
Bureau of Prisons NYM
Page 2 of 3
EFTA00073959
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg /t:
76318-054
Date of Birth:
01/20/1953
Sex: M
Facilit : NYM
Unit Team: A&O
Date:
07/09/2019 08:41
Provider:
PhD/Chief Psychologist
RECOMMENDATIONS
Inmate Epstein is currently on psychological observation pending suitable housing placement. In light of his current sex offense
charges and extensive media coverage on the television, he will need to be confined in a suitable housing unit. Inmate Epstein
will be seen daily while on psychological observation and will be seen for a psychological observation follow-up session once he
is released from observation. Inmate Epstein denied the need for psychological intervention, self-help materials, or follow-up.
He has been classified as a CC1-MH inmate at this time. CARE1-MH is indicative of an inmate who shows no significant level
of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention.
Suicide Watch:
A suicide watch is not warranted at this time
Completed by
PhD/Chief Psychologist on 07/09/2019 10:36
ti
e 129 of 148
p°
Withheld
exemption
(b)(6): (b) )
, (
)(C)
of the Freedom of Information
Generated 07/09,2019 10:36 by
PhD/Chief
Bureau of Prisons NYM
Page 3 of 3
EFTA00073960
Bureau of Prisons
Psychology Services
Suicide Risk Assessment
"SENSITIVE BUT UNCLASSIFIED'.
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex: M
Facilit : NYM
Unit Team: A&O
Date:
07/09/2019 08:41
Provider:
PhD/Chief Psychologist
Type of Housing:
Other Psychological Observation
Cell Accommodation: Single Cell
FINDINGS
This assessment and the resulting recommendations are based on the following sources of information:
Clinical Interview, Medical Record
Inmate Epstein was placed on
chological observation when he returned from court yesterday evening 7/8/19 for
precautionary reasons. He i
a suicide watch at this time.
Reason for Referral
Inmate Epstein is being seen
e risk assessment today for precautionary reasons. Inmate Epstein has various
risk factors for suicidality at thi
ing a high profile case with media attention, sex offense/trafficking charges.
pre-trial status, and he had a court
o
ing yesterday which could have given him bad news regarding his legal
situation. As such, this writer instruc
&D staff
s well as the Lieutenant's Office, to immediately notify the
psychology department when he returned fro
Inmate Epstein returned from court after duty hours and denied
suicidality. The aforementioned staff notifi
-call psychologist and inmate Epstein was placed on a precautionary
psychological observation status until psycholo
terview him this morning to conduct a suicide risk assessment.
Developmental History
Inmate Epstein denied any history of being the victim n
arifilfcatg physical or sexual abuse.
Educational History/Cognitive Impairment
Withheld
exemption
Inmate Epstein reported he obtained his high scholbrikie
a me graduate classes in the area of
mathematics.
Arrest History and Experience of Incanteisatilanpdom of Information
Inmate Epstein reported he has served time in Palm Beach County jail
apse charges (soliciting prostitution) in
the past. He is now being charged with sex trafficking, on a federal level.
Mental Health History
45
Inmate Epstein denied any history of mental health treatment, either on an inpat
t
)
ient basis. Inmate Epstein
denied any treatment in the past or present with psychotropic medication. He also d
acute mental health
symptoms at this time.
Self-Harm History
Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever
ging in any suicide
attempts or self-injurious behavior in the past.
Substance Abuse History
Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol.
Medical Concerns
Inmate Epstein denied any significant medical problems, other than a history of high triglycerides. He reported feeling
constipated at this time.
Current Problem
Inmate Epstein is currently on psychological observation due to his having multiple risk factors associated with
suicidality. He denies any suicidality at this time and has no mental health or suicide history. He is being seen for a
suicide risk assessment in an abundance of caution.
Current Mental Status
Level of Consciousness:
Alert and Oriented
Generated 07/09/2019 10:36 by
PhD/Chief
Bureau of Prisons NYM
Page 1 of 3
EFTA00073961
Inmate Name
Date of Birth:
Date:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
01/20/1953
Sex: M
Facilit : NYM
Unit Team: A&O
07/09/2019 08:41
Provider:
PhD/Chief Psychologist
Psychomotor Activity:
Normal
General Appearance: Normal
Behavior: Cooperative
Mood: Appropriate to Content
Thought Process: Goal Directed
Thought Content:
Normal
Inmate Epstein did not exhibit any acute psychopathology and exhibited a clear mental status.
Current Mental Status: Mr. EP
a neutral affect with appropri
and volume. His thoughts
irrelevant content. There
not engage in any bizarre or ina
explicitly denied recent and curre
commitment to life and safety, agree'
IN was alert and oriented. He was polite, calm, and cooperative in demeanor. He exhibited
e. Eye contact and hygiene were appropriate. The inmate spoke with normal rate, tone,
nized and coherent, with no loosening of associations or tangential. circumstantial, or
ce of perceptual disturbance, delusional ideation, or a formal thought disorder. He did
e behavior. He noted having normal sleeping and eating habits. Mr. EPSTEIN
eation, planning, and intent. He was future-oriented and expressed a
act staff immediately should he experience suicidal ideation.
RISK AND PROTECTIVE FACTORS
SSED•
This writer screened the inmate for a variety of
validated factors commonly associated with risk for self-harm and
suicide.
The following STATIC risk factors were assessed t
e
t and increase the inmate's risk for engaging in suicide related
behaviors: High Profile Crime. Lack of family connect'
s,
ender status
Of the DYNAMIC risk factors assessed, none were foun
it.
148
The following PROTECTIVE factors were assessedWil
:Gse the inmate's risk of suicide:Able to identify
reasons to live. Adequate problem solving skills. Denial of suici
tention/plans. Future orientation, View of death as
negative. Willingness to engage in treatment
(b)(6) (b)
(C)
As noted above. Inmate Epstein is a 66-yesflitidIrceaddrAidifilftlattn
factors for suicidality at this time
including a high profile case with extensive media attention. sex offense/tr
rges. pre-trial status. and he had a court
proceeding yesterday which may have given him bad news regarding his leg
Inmate Epstein also informed this
writer that his only family at this time is his brother, with whom he does not hav
Cl
tionship with.
Despite these risk factors, inmate Epstein possesses a number of protective factors atRfi
Inmate Epstein adamantly
denied any suicidal ideation, intention or plan. He was very future oriented and requeste
call, to meet with his
attorney. to take a shower. and to brush his teeth. He was eating his cereal when this writ
r
d said "I have my paper
spoon here." He reported he is going to have a bail hearing on Monday and believes he is go g t
sed from jail.
Inmate Epstein reported he is a Banker and has a "big business" in the community and that "bei
fun." He also
revealed he enjoys learning and teaching. He has confidence in his attorney and described him as
mpetent." Inmate
Epstein denied any mental health history or history of suicidality. He also reported none of his family members have mental
health histories. Inmate Epstein stated he is a mathematician and took post graduate classes in this area of study. Inmate
Epstein stated he has a support system in the community, including friends and other associates. Finally. inmate Epstein
demonstrated a good sense of humor and did not appear dysphoric, agitated or anxious. No acute psychopathology was noted.
Overall. inmate Epstein has numerous protective factors at this time that outweigh his risk factors for suicidality. He has a
positive outlook regarding his legal case, demonstrates no psychiatric symptoms, has no psychiatric or suicide history, and
verbalized a desire to be alive at this time and future orientation.
DIAGNOSIS-
No Diagnosis. No Dx - Current
CONCLUSIONS
The Overall Acute Suicide Risk for this Inmate is:
Low
Overall Chronic Suicide Risk for this Inmate is:
Absent
Generated 07/09,2019 10:36 by
PhaChiel
Bureau of Prisons NYM
Page 2 of 3
EFTA00073962
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg Et:
76318-054
Date of Birth:
01/20/1953
Sex: M
Facilit : NYM
Unit Team: A&O
Date:
07/09/2019 08:41
Provider:
PhD/Chief Psychologist
RECOMMENDATIONS
Inmate Epstein is currently on psychological observation pending suitable housing placement. In light of his current sex offense
charges and extensive media coverage on the television, he will need to be confined in a suitable housing unit. Inmate Epstein
will be seen daily while on psychological observation and will be seen for a psychological observation follow-up session once he
is released from observation. Inmate Epstein denied the need for psychological intervention. self-help materials, or follow-up.
He has been classified as a CC1-MH inmate at this time. CARE1-MH is indicative of an inmate who shows no significant level
of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention.
Suicide Watch:
A suicide watch is not warranted at this time
Completed by
PhD/Chief Psychologist on 07/09/2019 10:36
e 132 of 148
Withheld
• exemption
(b)(6) ; (b)
)(C)
of the Freedom of Information
Generated 07/09/2019 10:36 by
PhD/Chief
Bureau of Prisons - NYM
Page 3 of 3
EFTA00073963
Bureau of Prisons
Health Services
See Amendment
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/09/2019 08:41
Facility:
NYM
Amendment made to this note by
PhD/Chief Psychologist on 07/10/2019 09:20.
Page 133 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Bureau of Prisons - NYM
EFTA00073964
Bureau of Prisons
Psychology Services
General Administrative Note
"SENSITIVE BUT UNCLASSIFIED"
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01120(1953
Sex:
M
Facility: NYM
Date:
07/08/2019 10:41
Provider:
PhD/Chief
Reg St:
76318-054
Unit Team: MO
Comments
This writer consulted with Dr.
, Central Office, regarding inmate Epstein. Inmate Epstein has various risk
factors for suicidality including a high profile case with media attention. sex offense charges, pre-trial status, and a court
proceeding today which could otentially be giving him bad news regarding his legal situation. As such, when inmate
Epstein returns from court.
staff as well as Lieutenant's have been informed to immediately notify the psychology
department. If he returns after duty hours, the aforementioned staff were instructed to notify the on-call psychologist
and to place inmate Epstein on a watch status until psychology can conduct a thorough suicide risk assessment.
Completed by
PhD/Chief Psychologist on 07/08/2019 10:49
Page 134 of 148
Withheld pursuant to exemption
(b)(6) (b)(7)(A) (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07/08/2019 10:49 by
PhD/Chiel
Bureau of Prisons NYM
Page 1 ol 1
EFTA00073965
Bureau of Prisons
Psychology Services
Risk of Sexual Abusiveness
"SENSITIVE BUT UNCLASSIFIED—
Inmate Name:
EPSTEIN. JEFFREY EDWARD
Date of Birth:
01!20'1953
Sex:
M
Facility: NYM
Date:
07108:2019 09:35
Provider:
PsyD/PhD
Reg #:
76318-054
Unit Team: MO
Comments
Risk of Sexual Abusiveness
During the intake screening process. for Inmate Epstein. based on the documentation available at the time of the
screening. and Inmate Epstein's self-report. he was identified as being at risk for sexual abusiveness due to previous
perpetration of sexual abuse in the community or in an institutional setting, as evidenced by the following objective
criteria:
( ) Having a history of prior institutional violence or sexual abuse perpetration
(X ) Having a history of prior sexual abuse perpetration in the community
(X ) Having prior convictions of violent offenses
As required by P5324.11. Sexually Abusive Behavior Prevention and Intervention. Inmate Epstein was seen by
Psychology on today's date to assess his risk factors for sexual abusiveness. At the onset of this clinical contact, the
inmate was informed about the BOP requirements regarding PREA. Inmate Epstein indicated he understands the
institution's policy against engaging in sexual behavior. His risk factors for sexual abusiveness were assessed and
include:
( ) History of prior sexual victimization in prison
Page 135 of 148
( X ) History of prior prison sexual predation
withheld pursuant to exemption
( ) History of head injury with loss of consciousness
( ) History of childhood psychological, physical. sexi
yM(7)(A) (b)(7)(C)
( ) Witnessed family violence
( ) Antisocial Personality Disorder traitspfltielfebildrogilnieivnatiorsarrctiRrietttgsittoess
( ) Hypersexuality (defined by eight or more orgasms a week prior to prison)
( ) Hypermasculinity
( ) Other:
Based on this clinical assessment. the inmate is considered to be at:
(X ) Low Risk of Abusiveness at this facility (Note: Even though this inmate is judged to be at low risk of sexual
abusiveness, an unforeseen change in risk factors may significantly alter his risk level.). Programming
recommendations included sex offender treatment. Inmate Epstein declined programming recommendations.The
inmate understands the procedure for contacting Psychology for routine or emergent services.
( ) Moderate Risk of Abusiveness. The Unit Team and Correctional Staff have been notified regarding Psychology
staffs recommendation that he not be housed in a cell with any inmates identified as at increased risk for sexual
victimization. Psychology also recommends a greater level of supervision regarding his work and education
assignments. Programming recommendations include XXXXX. Inmate =inmateLastName is agreeable to/ declined
programming recommendations.
( ) High Risk of Abusiveness. It is recommended this inmate be housed in the Special Housing Unit in accordance with
P5324.11 to "keep separate those inmates at high risk of being sexually victimized from those at high risk of being
sexually abusive" until Correctional Services and Correctional Programs staff can assess his appropriateness for
general population at this facility. This inmate should not be housed with any inmates judged to be at an increased risk
for sexual victimization. Programming recommendations include XXXXX. Inmate =inmateLastName is agreeable tol
declined programming recommendations.
Generated 07/08/2019 09:41 by
PsyD.'PhD
Bureau of Prisons NYM
Page 1 ol 2
EFTA00073966
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Sex:
M
Facility: NYM
Date:
07/08/2019 09:35
Provider:
PsyD/PhD
Reg #:
76318-054
Unit Team: A&O
Completed by
PsyD/PhD on 07/08/2019 09:41
Page 136 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A) ; (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07108/2019 09:41 by
PsyD/PhD
Bureau of Prisons - NYM
Page 2 of 2
EFTA00073967
Bureau of Prisons
Psychology Services
Intake Screening
"SENSITIVE BUT UNCLASSIFIED••
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex: M
Facilit : NYM
Unit Team: A&O
Date:
07/08/2019 09:24
Provider:
. PsyD/PhD
Limits of Confidentiality
Limits of confidentiality were reviewed with inmate EPSTEIN. He expressed an understanding of the limits of confidentiality
and consented to be interviewed accordingly.
Data Source(s)
The following data sources were reviewed in conjunction with this Initial Intake Evaluation: Self-Report. SENTRY, Staff
Observation.
Inmate Epstein is a 66-year-old. Black male who was seen by Psychology Services due to newly arriving at MCC-NY. He
denied a history of mental health treatment on his Psychology Services Intake Questionnaire.
Mental Health History and Current Symptoms
No history of mental health issues was noted.
No history of prior mental health treatment was noted.
No current mental health symptoms were noted.
No suicidal ideation, attempts, or self-harm were noted.
Substance Abuse
No history of substance abuse was noted.
No history of substance abuse treatment was noted.
Sex Offenses
No sexual offense convictions were noted.
Page 137 of 148
No history of sexual predation in a correctional sltigigawied
rsuant to exemption
Relevant Psychosocial History
Noteworthy psychosocial issues: Other.
(b)(6) ; (b)(7)(A); (b)(7)(C)
Inmate Epstein is currently incarcerAtchd
U oex Toff4king. Ft spoiled he wap previously incarcerated three months for
prostitution. Inmate Epstein statedWI! 0;1p &918 d8bITSARAIViy%Rfreft. He revealed he was living in New York.
He stated he completed high school. He stated he was employed in banking work prior to his incarceration.
Adjustment to Incarceration
Adjustment to incarceration concerns were identified: Other.
SEXUAL ABUSE HISTORY
Inmate Epstein denied being the victim of physical or sexual abuse. He is currently charged with sex trafficking and has
previously been charged with prostitution. He was informed of the programs offered by MCC-NY as well as the Bureau of
Prisons. Additionally, he was informed of this institutions self-help program. Inmate Epstein reported he was not currently
interested in any treatment programs.
MENTAL STATUS:
Inmate Epstein appeared calm, controlled, without signs of psychomotor agitation or retardation. He was fully cooperative,
maintained good eye-contact. and related in an interpersonally appropriate manner with interviewer. Speech and thought
processes were organized. coherent, logical, and goal-directed.
Based on informal assessment during this interview, this inmate's cognitive functioning appeared within normal limits, as
reflected by adequate long and short-term memory, good attention, and appropriate concentration during interview, as well
as adequate receptive and expressive language skills. Inmate denied any current sleep disturbances and described his
appetite as adequate.
This inmate denied recent or present morbid thoughts, passive or active suicidal ideation, intent or plan and contracted for
safety. This inmate's verbalizations were optimistic, future oriented, and without indications of helpless or hopeless
thinking. Inmate Brown denied any familial history of suicide behaviors or attempts.
This inmate was provided with supportive psychotherapy. and psycho-education to strengthen coping skills and facilitate
adjustment to incarceration.
Findings
Care Level:
CARE1-MH
Generated 07/09,2019 09:30 by
PsyDiPhD
Bureau of Prisons NYM
Page 1 of 2
EFTA00073968
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex: M
Facilit : NYM
Unit Team: A8O
Date:
07/08/2019 09:24
Provider:
. PsyD/PhD
Inmate EPSTEIN denied any history of mental health symptoms or treatment. He denied any current mental health symptoms.
He does not meet criteria for any current psychological diagnosis. He meets criteria for Mental Health Care Code 1.
CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness
and demonstrates no need for regular mental health intervention.
Recommendations
The following psychological services are recommended: Other.
Inmate EPSTEIN was educated about both routine and emergency procedures for contacting Psychology staff. He does
not appear to be in distress at this time. He agreed to contact psychology if he feels he needs psychology services in the
future. He meets criteria for CC1 and does not require scheduled follow up at this time.
Completed by
. PsyD/PhD on 07/08/2019 09:30
Page 138 of 148
Withheld pursuant to exemption
(b)(6) (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Generated 07108:2019 09:30 by
PsyDiPhD
Bureau of Prisons NYM
Page 2 of 2
EFTA00073969
Federal
Bureau of
Prisons
U.S. Medical Center for Federal Prisons
1900 W. Sunshine Street
Springfield, MO 65807
417-874-1621
••• Sensitive But Unclassified
Name EPSTEIN, JEFFREY
Reg # 76318-054
DOB
01/20/1953
Sex
M
Facility MCC New York
Collected 07/09/2019 13:34
Order Unit E06-547U
Received 07/10/2019 10:44
Provider
MD
Reported 07/10/2019 14:46
LIS ID
188191004
CHEMISTRY
Sodium
Potassium
Chloride
CO2
BUN
Creatinine
eGFR (IDMS)
137
4.7
99
27
17
1.05
>60
137-148
3.5.5.0
99.114
22-30
7.22
0.66.1.25
mmol/L
mmol/L
mmol/L
mmol/L
mg/dL
mg/dL
GFR units measured as mUmini1.73 m^2. If African American multiply by 1.210.
A calculated GFR <60 suggests chronic kidney disease if found over a 3 month period.
Calcium
9.8
8.5-10.9
mg/dL
Glucose
102
70.110
mg/dL
AST
H
57
11.55
U/L
ALT
62 Page 139 of 148
11-66
U/L
Alkaline Phosphatase
64
41.133
U/L
Bilirubin, Total
Withheld pursuant to exemption
0.2.1.3
mg/dL
Total Protein
77
6.0-8.2
g/dL
Albumin
(b)(6?; (b)(7)(A) ; (b)(7)(C)
4.4
3.6.5.1
g/dL
Globulin
of the Freedom otlaformation and Privacy Act
2.0.3.7
g/dL
Alb/Glob Ratio
1.50
1.00-2.30
Anion Gap
10.2
9.0.19.0
BUN/Creat Ratio
16.1
5.0.30.0
Cholesterol
H
216
<200
mg/dL
Triglycerides
H
413
10-150
mg/dL
Calculation of LDL is not appropriate for samples with a triglyceride greater than 400 mg/dL. Therefore the LDL is not calculated.
HDL Cholesterol
L
31
40.60
mg/dL
Chol/HDL Ratio
H
6.9
0.0.4.0
HEMATOLOGY
WBC
7.6
4.3-11.1
K/uL
NRBC%
0.0
RBC
5.42
4.46-5.78
M/uL
Hemoglobin
15.6
13.6-17.6
g/dL
Hematocrit
47.8
40.2-51.4
MCV
88.2
82.5-96.5
fL
MCH
28.8
27.1-34.9
Pg
MCHC
L
32.6
33.0-37.0
g/dL
RDW-CV
12.8
12.0-14.0
Platelet
338
130-374
K/uL
FLAG LEGEND
L=Low LI=Low Critical H=High H!=High Critical
A=Abnormal A! =Abnormal Critical
Page 1 of 3
EFTA00073970
Federal
Bureau of
Prisons
U.S. Medical Center for Federal Prisons
1900 W. Sunshine Street
Springfield, MO 65807
417-874-1621
•" Sensitive But Unclassified •••
Name EPSTEIN. JEFFREY
Reg # 76318-054
DOB
01/20/1953
Sex
M
Facility MCC New York
Order Unit E06-547U
Provider
MD
Collected 07/09/2019 13:34
Received 07/10/2019 10:44
Reported 07/10/2019 14:46
LIS ID
188191004
HEMATOLOGY
MPV
10.4
6.9-10.5
fL
Neutrophils
58.7
Therapeutic decision mak ng should be based on absolute values, rather than percentages
Lymphocytes %
25.0
Monocytes %
11.1
Eosinophils %
4.1
Basophils %
0.8
Immature Granulocytes %
0.3
0.0-5.0
%
Neutrophils #
4.4
1.9-6.7
K/uL
Lymphocytes #
1.9
1.3-3.7
K/uL
Monocytes #
0.8
0.3-1.1
K/uL
Eosinophils #
0.3
0.0-0.5
K/uL
Basophils #
0.1 Page 140 of 148
0.0-0.1
KJuL
Immature Granulocytes #
0.02
0.00-0.50
10^3/uL
Withheld pursuant to exemption
HEMNI-Pf#4081A(7)(c)
Hemoglobin A1C
5.7 6.4 Increased Risk
H
6.3
of the Freedom of Information and Privacy Act
<5.7
> 6.4 Diabetes
IPR
SEROLOGY
Non-Reactive
Results may be affected in patients with severely advanced immunosuppression.
Non-Reactive
FLAG LEGEND
L=Low LI=Low Critical
H=High H!=High Critical
A=Abnormal A! =Abnormal Critical
Page 2 of 3
EFTA00073971
Federal
Bureau of
Prisons
U.S. Medical Center for Federal Prisons
1900 W. Sunshine Street
Springfield. MO 65807
417-874-1621
"' Sensitive But Unclassified "'
Name EPSTEIN. JEFFREY
Reg # 76318-054
DOB
01/20/1953
Sex
M
Facility MCC New York
Order Unit E06-547U
Provider
MD
Collected 07/09/2019 13:34
Received 07/10/2019 10:44
Reported 07/10/2019 14:46
LIS ID
188191004
HIV
HIV 1/2
Negative
Screening test - See confirmatory testing for Reactive results
Page 141 of 148
Withheld pursuant to exemption
(b)(6) (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Negative
FLAG LEGEND
L=Low L!=Low Critical
H=High H!=High Critical
A=Abnormal A! =Abnormal Critical
Page 3 of 3
EFTA00073972
Bureau of Prisons
Health Services
Cosign/Review
Inmate Name:
EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
Date of Birth:
01/20/1953
Sex:
M
Race:
WHITE
Encounter Date: 07/10/2019 16:58
Provider:
Lab Result Receive
Facility:
NYM
Cosigned by
on 07/14/2019 18:12.
Page 142 of 148
Withheld pursuant to exemption
(b)(6) ; (b)(7)(A); (b)(7)(C)
of the Freedom of Information and Privacy Act
Bureau of Prisons NYM
EFTA00073973
8P-A.0469
JUN 10
U.S. DEPARTMENT OF JUSTICE
I-UV COUNSELING DOCUMENTATION
FEDERAL BUREAU OF PRISONS
Directions:
Use the following criteria to counsel the patient who is tested for the HIV anibody. Check off each item as they are
discussed. Write NA beside any item that is inappropriate to the situation. Thereverse side of this form will be
utilized to document seronegative and inconclusive test result. Then file in the patient's
reco rd,
documenting in progreis notes that counseling was completed.
PRETEST:
Y e 1.
Explain purpose of session.
2.
Explain..confidentiality. .
3.
Explain HIV antibody test.
a.
What HIV is
b.
What the test is
T
Test Procedure
c.
Meaning of test results
_de..
f.
q.
Potential need for additional testing
Inability of detecting early infection (false negatives)
Significance of a positive test.
_, ,
4.
Ust risk factors/clinical signs: (check all that apply)
Injecting drug use, sharing drug or tattoo equipment
— b..
•
d.
e.
f. q.
Clinical sts: fever or illness oMilikhOISIINUOMIltitjirftlIfitenklf AIDS opportunistic. infections.
Pregnant female
Other.
Exposure: recent occupational or non-occupational exposure/incldent,
i
(b)(6); (b)(7)(A); (b)(7)(C)
.
,
A
Unprotected or multiple sex partners
Page 143 of 148
Treated for sexually transmitted infections, hepatitis, or TB
of the rreedom of intormaticirrand KiVaty Mr
-
----6. •
Obtain informed consent (when applicable).
.
___
-.6.
Risk Reduction Behaviors. Educational material given.
/7.
Patient ReactionslComments.
Explain how the patient will be notified of the result.
The above information has been explained to m,e in a language I can understand.
SignatUre of Inmate
^
..
Signature of Staff uunseloci
,Se S
,N,Q0
Date:
Institution:
File in tty$Medical Record: Section 6.
Prescribed by P6190
Replaces OPS489.061 &APR
4
EFTA00073974
BP-S359.060
MEDICAL TREATMENT IEFUSAL
CDFRM
SEP 05
U.S. DEPARTMENT OF JUSTICE
FEDERAL BUREAU OF PRISONS
7-9-2019
Date
I JEFFREY EPSTEIN
76318-054 , refuse treatment recommended by the Federal
Bureau of Prisons Medical staff for the following condition(s):
DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY:
Rectal and genital examination
The following treatment(s) was/were recommended:
Rectal and genital examination
Page 144 of 148
Withheld pursuant to exemption
(b)(6): (b)(7)(A) : (+7)(C)
Federal Bureau of Prisons Medical sta
n
ffinembers,ha.ve carefully.explaiged to me that the following
9iOn
possible consequences and/or cor
Eifi
V9gCliffecrtFeaWiyibfusal to accept treatment:
Undetected and untreated medical condition.
I understand the possible consequences and/or complications, listed above, and still refuse
recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and
release the Bureau of Prisons and its employees from any and all liability for respecting and following my
expressed wishes and directions.
Counseled by
kmi
W.1d:cal Omcc
MCC NY
Signature of Witness
-2019
Date
Patient's Signal
7/1/(5
Date
NYM-NEW YORK MCC
n 14 )5
Date
EFTA00073975
BP-S358 06C
MEDICAL TREATMENT REFUSAL
CDFRM
SEP CS
U.S DEPARTMENT OF JUSTICE
FEDERAL BUREAU OF PRISONS
7-24-2019
Date
I, JUT:REY EPSTEIN
76318.054 refuse treatment recommended by the Federal
Bureau of Prisons Medical staff for the following condition(s):
DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY:
EYE DOCTOR EVALUATION
The following treatments) was/were recommended:
EYE DOCTOR EVALUATION.
Page 145 of 148
Withheld pursuant to exemption
(b)(6) (b)(7)(A) : (b)(7)(C)
Federal Bureau of Prisons Medical nrpaspagsolmf8rFaofAmpixakytiibto me that the following
possible consequences andlor complications may result because of my refusal to accept treatment:
INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES.
I understand the possible consequences and/or complications, listed above, and still refuse
recommended treatment. I hereby assume all responsibility for my physical andfor mental condition, and
release the Bureau of Prisons and Its employees from any and all liability for respecting and following my
expressed wishes and directions.
ID
7-24-2019
Date
NYM--NEW YORK MCC
7re-cie-
EFTA00073976
BP-A0618
JUN 16
U.S. DEPARTMENT OF JUSTICE
A&O DENTAL EXAMINATION
(Initial Clinical Dental Findings)
FEDERAL. BUREAU OF PRISONS
Occlusion:
• N
X1
2
3
4
5
9
7
8
0 1011 1213
14
15 18;
32
3
1
1
!
E
J
30 29 28 21 28 25 24 23 22 21 20 19
18
17
9
Pa
Dental Prostheses at Intake:
Yes
Type:
Age:
Condition:
Intra-oral Photos Taken:
Yes
C
Instructed how to obtain argent and non-urgent dents: care:
Yes: I
No:
Oral Hygiene:
CPITN:
Gocd
Far
Poor
3
3
2-
3
Head & Neck / Soft Tissue:
D:
M:
I
F:
p 146 of 148
(b)(6):
Classification:
CLr
Pain Scaie:
PIO
nt to exempt-was.' Tan
09
)(AR/
/115 /1.1"-r2
R SS ‘,G2 21/2 SUU-2- •
of the Freedom of Int rr itoye And c2r z.„Aic y t ay.
cayoLiA 0.10 set _fe d
Radiographs Taken: (DocJrnent findings on A&O encounter)
Yes
Treatment Polities:
None:
Radiographs authorized:
PAs:
IN/s:
Panorex-.
nt Name:
Non-urgent:
non-urgent
Urgent: Referred to Sick Call:
Prophylaxis authorized:
Yes
No
(Approve: yak 18 months from examination date)
£
Dentist nanl
1>Ds
ignaturc Block/Stamp:
Number:
76 3 IT- os-M
PDF
Institution:
MCC NEW YORK
Date:
7-26
Chret Dental Officer
MCC New York
Prescribed by P6400
Replaces BP-A0618 cf
N 10
EFTA00073977
BP-S358 06O
MEDICAL TREATMENT REFUSAL
CDFRM
SEP 05
U.S DEPARTMENT OF JUSTICE
FEDERAL BUREAU OF PRISONS
7-24-2019
Date
I JEFF REY EPSTEIN
76318-054 , refuse treatment recommended by the Federal
Bureau of Prisons Medical staff for the following condition(s):
DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY:
EYE DOCTOR EVALUATION.
The following treatment(s) was/were recommended:
EYE DOCTOR EVALUA HON
Page 147 of 148
Withheld pursuant to exemption
(b)(6) (b)(7)(A) (b)(7)(C)
Federal Bureau of Prisons Medical INteWiatfisdP R&M IMUNcrispia,AgiVtto me that the following
possible consequences and/or complications may resu t
cause of my refusal to accept treatment:
INABILITY TO DIAGNOSE CURRLNT OP1HALMOLOGIC DISEASES.
I understand the possible consequences and/or complications, listed above, and still refuse
recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and
release the Bureau of Prisons and its employees from any and all liability for respecting and following my
expressed wishes and directions.
7-24 2310
Cou
Date
Patient's Sign
Dale
NYM--NEW YORK MCC
EFTA00073978
BP-S358.060
SEP C5
MEDICAL TREATMENT REFUSAL
CDFUM
U.S. DEPARTMENT OF JUSTICE
FEDERAL BUREAU OF PRISONS
7-10-2019
Date
I, JEFFREY EPSTEIN
76318-054 , refuse treatment recommended by the Federal
Bureau of Prisons Medical staff for the following condition(s):
DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY:
66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR.
The following treatment(s) wasfwere recommended:
CHEST X-RAY
Page 148 of 148
Withheld pursuant to exemption
(b)(6) (b)(7)(A). (b)(7)(C)
Federal Bureau of Prisons Medica4 ta7rmyrbgirsntfoiryinr aenfAxvemlained to me that the following
possible consequences and/or cSm TicaiTas may resuff because
refusal to accept treatment:
WORSENING THE CONDITION IF THERE IS ANY FINDINGS
I understand the possible consequences and/or complications, listed above, and still refuse
recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and
release the Bureau of Prisons and its employees from any and all liability for respecting and following my
expressed wishes and directions.
. X-RAY
7-10-2019
Counseled by
Date
Patien
Signature
Date
Signature of Witness
NYM-NEW YORK MCC
EFTA00073979
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| Filename | EFTA00073831.pdf |
| File Size | 20777.5 KB |
| OCR Confidence | 85.0% |
| Has Readable Text | Yes |
| Text Length | 230,718 characters |
| Indexed | 2026-02-11T10:26:20.493030 |