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
ESRD on hemodialysis, non-dialysis day: AV fistula in the left arm with a palpable thrill and audible bruit, the access limb protected (no BP or venipuncture), weight and volume status consistent with the dry-weight target, no uremic symptoms, on the renal diet and phosphate binder per order. Licensed assessment of the access and volume status and coordination of the dialysis plan required; the potential for fluid-electrolyte change makes daily skilled observation necessary at SNF level. Supports the Section O dialysis item and the renal care-plan goal.
Model normal 2
Acute-kidney-injury recovery: intake and output balanced, urine output improving, weight stable, no edema, electrolytes trending toward normal on the last lab, tolerating the renal diet. Skilled observation required to detect fluid-electrolyte change and evaluate recovery; supports Section I and the renal goal.
