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
Weight stable at 152 lb (vs 151 lb last week), intake averaging 75% on the mechanically altered (IDDSI Level 5) diet, no coughing or wet voice with the aspiration precautions in place (upright, small bites, chin tuck) — RN monitoring confirms no significant weight change (below the K0300 threshold) and supports the Section K diet item and the nutrition care-plan goal.
Model normal 2
Enteral feeding at the ordered rate, gastric residual within policy, tolerated without distension or reflux; PEG site clean without leakage or granulation; free-water flushes given per order — RN monitoring of tolerance and site required; supports the Section K feeding-tube item and the nutrition goal.
