Visiting Nurse Reports for Former President Harry S. Truman

Confidential Dris copy PLEASE CHECK M SOURI - KANSAS METROPOLITAN INITIAL REFERRAL Inter-Agency Referral Form PROGRESS NOTES RENEWAL Patient TRuman, Harry S. Hosp. # From VISITING NURSE ASSN. Birth Date 5-8-84 Sex m SM W D Sep. Medicare #488-40-696A OF GREAFFEST KANSAS CITY 4128 BROAD WAY Address: Apt. # Floor. OPD # Address KANSAS CITY, MO. 64111 219 Delaware 117 S.S. # Tele. No. PHONE JE 1. - E200 (DIRECTIONS) STREET C.T. Unit Independence CITY Jackson COUNTY ZIP 64050 CODE CL-2-7107 TEL. NO. To. Malloce Groham m.d. AGENCY Responsible Person Relationship Address 815 c. 6 3rd Hosp. Adm. Date Disch. Date K.C. mo. Next app't date In clinic (name) Date of Referral DIAGNOSIS AND PROGNOSIS: Functional Limitations: X Has Tuberculosis been ruled out Yes No X-Ray TB Tests Other Communicable Disease ? Allergies ? Has Diagnosis & Prognosis been told patient? Family ? PHYSICIAN'S RECOMMENDATIONS AND PLAN OF RX must include instructions for care; treatment; diet; activities; ( name of medication; dosage; method and frequency; supplies and Treatment: appliances needed ) Insert Dueslax supp. prn for bowe regulation bluts mema or S.S. mema to remove importion pen. Medication: Diet: Regular Activity: not restricted YES NO PATIENT IS SHOME BOUND" AND IN NEED OF REQUESTED SERVICES: MEDICAL SOCIAL WORKER MAY PROVIDE-SERVICES AT DISCRETION OF PROFESSIONAL NOME HEALTH AIDE MAY BE ASSIGNED AT DISCRETION OF PROFESSIONAL NURSE. YES NO PATIENT is BOUND" AND CARE IS RELATED TO PRIOR HOSPITALIZATION, I hereby certify this person for home health services: Date 2-20-70 Signature Specialty Tele. # & Ext. REPORT OF DIETITIAN, MEDICAL SOCIAL WORKER, PHYSICAL THERAPIST, OCCUPATION THERAPIST, ETC. Date Signature Specialty Tele. # & Ext. WHITE-RECEIVING AGENCY PINK-RECEIVING AGENCY YELLOW-ORIGINATING AGENCY FILE COPY PHNC 9-67