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
Parameter-based vital-sign surveillance: temperature 98.4°F, heart rate 74, respiratory rate 18, blood pressure 124/76 within the ordered parameters, SpO₂ 96% on room air, pain 2/10 — all stable versus the prior shift and within parameters. Licensed interpretation required to trend the values against the parameters and detect an early deteriorating pattern given the diagnosis of [primary skilled condition]; on this post-acute stay the parameter-based surveillance is part of the daily skilled need. Supports the observation basis and the care-plan goal.
Model normal 2
Post-event monitoring with tightened parameters: vitals obtained on the ordered frequency and interpreted against the parameters, a mild expected variation noted and correlated with activity, no value outside the notify thresholds. Skilled trending and interpretation required to catch a change early; supports the observation basis and the goal.
