Autism and Accommodations in Higher Education: Insights from the Autism Community

Client initials:

Age:

Gender:

Primary Language

Allergies:

Code status:

Wt:

Ht:

BMI:

Admit date:

Hospital Day #

Isolation Y N

Indication

Bleeding Precautions Y N

Indication

Fall Risk Y N

Aspiration Risk Y N

Admitting diagnosis/symptoms (chief complaint upon admission):

Current medical diagnoses:

Summary of hospitalization to date: (what happened from admission to time you took care of them)

PMH/PSH:

Social history (ethnicity, occupation, marital status, family support, living situation):

VS freq:

Diet:

Blood sugars frequency:

Activity order:

Oxygen order:

Respiratory Tx:

Dressing changes:

Other relevant orders:

Physical Assessment Findings

Analysis of Findings

(Explain significance related to current diagnosis and/or PMH.)

Vital signs:

I:

O:

Why and how it relates to the patient’s diagnosis.

Neurological/Sensory:

Cardiovascular:

Respiratory:

Gastrointestinal & Nutrition:

Musculoskeletal:

Genitourinary/Reproductive:

Integumentary (including incisions and drains):

IV Assessment:

Pain:

Psychosocial:

Date

Lab Test

Abnormal Lab Results

Normal Range

Rationale for performing test

Relationship between/among test results with client’s condition

Why and how it relates to the patient’s diagnosis.

Date

Test

Reason for test

Results/Findings

Analysis of relationship between diagnosis test and client’s condition

“my dog is named blue” (Davis, 2020, p1)

Why and how it relates to the patient’s diagnosis.

Trade Name

Generic Name

Medication Classification

Therapeutic Use

Major adverse effects

Time dosage

Route of administration

Nursing Consideration

Significant information

Significant information