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
Immunosuppression with protective precautions (post-transplant): the resident on the immunosuppressant regimen per order with protective precautions in place, afebrile with no infection signs, and counts/levels monitored per order; the heightened surveillance recognizes that the infection response is blunted. Licensed infection surveillance and precaution management required, because a subtle change may be the only sign of a serious infection; a daily skilled need. Supports Section O/N and the care-plan goal.
Model normal 2
IVIG administration: the ordered IVIG infused per the titration protocol with baseline and interval vitals stable and no infusion-reaction signs (no headache, flushing, chills, or dyspnea), the rate advanced per order, and premedication given per order. Skilled administration and reaction monitoring required — a covered skilled procedure; supports the Section O item and the goal. (Access detail routes to the Lines/Drains/Devices reference.)
