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 |
|---|
Delirium-superimposed-on-dementia surveillance with new BPSD management: the resident’s moderate dementia at the documented baseline (no acute fluctuation, CAM negative), with a new pattern of afternoon agitation managed through a skilled non-pharmacologic plan (identified triggers, structured routine, redirection, and environmental measures) that reduced the episodes, and a medical-cause screen negative. Licensed distinction of delirium from the baseline and skilled management and evaluation of the new BPSD required; on this stay that is the skilled element. Supports Section C/E and the care-plan goal. (Psychotropic/GDR detail routes to the Behavioral reference.) |
Model normal 2 |
|---|
Dementia complicating a skilled comorbidity: the resident with dementia recovering from a hip fracture, with the dementia integrated into the rehabilitation plan (adapted communication and cueing, safety measures, and consistency) so that the skilled rehabilitation can proceed. Skilled management and evaluation of the plan complicated by dementia required; the primary skilled documentation lives in the comorbidity’s reference (here, Musculoskeletal). Supports the goal. |