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
Behavior monitoring this shift: 2 episodes of late-afternoon agitation, both resolved with redirection and a walk (non-pharmacologic), no PRN psychotropic needed — documented to support the Section E behavior item, the F758 non-pharm-first expectation, and the GDR care-plan goal; the antipsychotic remains at the reduced dose with the target psychotic symptom stable.
Model normal 2
Antidepressant monitoring: mood improved, PHQ trend down, no adverse effects, appetite and sleep improved — RN assessment confirms the medication is meeting its documented indication (major depressive disorder) with no unnecessary-drug concern; supports Section D/N and the mood care-plan goal.
