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-tympanoplasty day 4: the operative ear with a clean external dressing, no purulent drainage, mild expected fullness only, no fever, and the surgeon’s precautions (water precautions, no nose-blowing, no straining) observed and reinforced. Licensed observation for a post-operative complication and enforcement of the precautions required; a daily skilled need at SNF level. Supports the Section B hearing item and the ear care-plan goal; teaching of the precautions ongoing.
Model normal 2
Hearing-deficit management enabling the skilled plan: the hearing aid in place and functioning with fresh batteries, communication strategies used (face the resident, reduce background noise), and the resident participating in the skilled teaching and therapy that the corrected hearing makes possible. Skilled management of the deficit to enable participation and to distinguish a hearing deficit from confusion required; supports Section B and the goal.
