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
Whole-person surveillance on a complex post-acute resident: afebrile, energy and activity tolerance at baseline, intake averaging 75%, weight stable, participating in the plan; the interacting problems (the primary diagnosis plus comorbidities) reviewed and the unskilled care confirmed to be achieving its purpose. Licensed systemic observation and management-and-evaluation of the multi-problem plan required to detect an early change and keep the plan working safely; a daily SNF-level need. Supports Section K/I and the care-plan goals.
Model normal 2
Management & evaluation of a multi-problem plan: a resident with several interacting conditions on multiple parameter-based orders — the regimen reconciled after a change, the constitutional signs correlated across problems, and the unskilled care (diet, mobility, monitoring) verified. Skilled RN oversight required to integrate the problems; supports the care-plan goals.
