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
Restorative ambulation program: resident ambulated 75 ft with a rolling walker and contact-guard assist ×1, 20 minutes, 6 of the last 7 days per the program, tolerating without SOB (SpO₂ 96%) — RN evaluation confirms the maintenance goal is being met and supports O0500 walking-training coding and the Section GG mobility item; program continued, next RN re-evaluation dated.
Model normal 2
Restorative ROM and splint program: passive/active-assisted ROM to bilateral upper extremities 15 minutes, resting hand splint applied per schedule with skin checks, no contracture progression — RN evaluation confirms the program is preventing decline; supports O0500 (ROM, splint/brace assistance) and the functional goal.
