3. Normal findings — documented with skill justification
Each normal line pairs the finding with the reason a licensed clinician was required and why today, and states values against the ordered parameter or the specific prior value — never bare “WNL” or “at baseline.”
Model normal 1
Dehydration recovery on IV fluids: the ordered isotonic fluid infusing at the ordered rate through a patent site, intake and output balancing and urine output improving, mucous membranes moist and skin turgor improved, blood pressure and heart rate normalized with no orthostatic drop, and electrolytes trending toward normal on the last lab. Licensed administration and monitoring of the IV fluids and daily fluid-electrolyte assessment required; a covered daily skilled service at SNF level. Supports the Section K fluids item and the hydration care-plan goal.
Model normal 2
Fluid balance in a complex resident: intake and output monitored against the ordered parameters and correlated with the weight and the diuretic order, euvolemic with no edema or dehydration signs. Skilled fluid-balance judgment required to keep the resident euvolemic given the interacting orders; supports Section K and the goal.
