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
Post-operative recovery day 5 (across the surgical types), progressing: the incision well-approximated with no drainage or surrounding erythema, any drain patent with decreasing output, pain controlled to allow full therapy participation, VTE prophylaxis administered with no calf signs, bowel function returning and lungs clear (incentive spirometry used), and the surgeon’s precautions and activity order observed. Licensed post-surgical surveillance for infection, bleeding, VTE, ileus, and atelectasis, together with rehabilitation-nursing carryover, required; a daily skilled need. Supports Section GG/O/N and the rehabilitation care-plan goal.
Model normal 2
Rehabilitation-nursing carryover with pain enabling therapy: transfers and mobility performed with the ordered assist and precautions maintained, restorative reinforcement of the therapy program delivered, and pain controlled specifically to allow participation, with the incision intact. Skilled evaluation of the post-surgical rehabilitation plan and safe carryover required; supports Section GG and the goal.
