Visiting Nurse Reports for Former President Harry S. Truman

Confidential PLEASE CHECK L pibem MISSOURI - KANSAS METROPOLITAN INITIAL REFERRAL PROGRESS NOTES Inter-Agency Referral Form RENEWAL Patient Truman HARRY S. VISITING NURSE ASSN. Hosp. # From OF GREATER KANSAS CITY Birth Date 5-8-84 Sex m S/M/W D Sep. Medicare # 4128 BROADWAY Address: Apt. # Floor OPD # Address KANSAS CITY, MO, 64111 219 DelawaRe 117 S.S. # Tele. No. PHONE JE. 1 - (DIRECTIONS) STREET C.T. Unit Independence CITY COUNTY Jackson ZIP 64050 CODE CL-2-7107 TEL. NO. To Wallace Graham M.D. AGENCY Responsible Person Relationship Address 1815 E. 63 rd Hosp. Adm. Date Disch. Date K.C. mo. Next app't date In clinic (name) Date of Referral DIAGNOSIS AND PROGNOSIS: Practitis Trical Impaction Has Tuberculosis been ruled out Yes No X-Ray TB Tests Other Communicable Disease ? none Allergies Jerramyan sulfan Has Diagnosis & Prognosis been told patient ? yes Family ? yes PHYSICIAN'S RECOMMENDATIONS AND PLAN OF RX ( name of medication; dosage; method and frequency; supplies and must include instructions for care; treatment; diet; activities; Treatment: Alute appliances needed. mema or S.S Cnema to remove impaction prew. Drsure Ducolas supportunity from for bowel regulation Medication: YTIMUMMOO SECHTO so HTJASH 011809 Y& TROSES Pericolose IT H.S. (ode to it whom asset and and find Diet: Regular would in and word Larra PN-86-H wing Activity: not restricted or lands at MEDICAL SOCIAL WORKER MAY PROVIDE SERVICES AT DISCRETION OF PROFESSIONAL YES, NO HOME HEALTH AIDE MAY BE ASSIGNED AT DISCRETION OF PROFESSIONAL NURSE. YES. NO for I Date hereby 6-28-6 certify Signature this person home health services; Specialty Ten Surge Tele. # & Em 3-6409. REPORT OF DIETITIAN, MEDICAL SOCIAL WORKER, PHYSICAL THERAPIST, OCCUPATION THERAPIST, ETC. allowal in wish selections prises in abong initial work 962 various promosing with the and proteinaffer s burds been principal effective with words it invited the is MARA - sib situation mailer timin arrand dum M.r ministers work August Date Signature Tele. # & Ext. WHITE-RECEIVING AGENCY AGENCY YELLOW-ORIGINATING AGENCY FILE COPY PHNC 9-67