“Normal/at-baseline” means the patient is at or progressing along the expected recovery for the condition and orders. Each line states the finding, the baseline comparison, and the skilled reason a nurse was required — a bare “ambulated without difficulty” does not qualify.
Strength symmetric and at or improving from the patient’s baseline by manual muscle testing.
Range of motion at the affected joint within the expected post-operative or baseline arc, without new restriction.
Gait steady with the prescribed assistive device over the assessed distance, without loss of balance.
Post-operative precautions and weight-bearing status intact and correctly observed.
Joints without new swelling, warmth, or effusion; chronic findings unchanged from baseline.
Pain stable or decreasing and controlled with the current regimen, without new functional limitation.
Assistive device fitted correctly and used safely; transfers performed within the patient’s baseline.
