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
Lymphedema management with compression: the affected arm with girth improved versus the prior measurement on the ordered compression, applied correctly with the limb protected (no BP or venipuncture), skin intact and moisturized without breakdown, and no signs of cellulitis (no spreading erythema, warmth, or fever). Licensed limb measurement, skilled compression, and infection surveillance required to reduce the edema and prevent cellulitis; a daily skilled need. Supports Section I and the care-plan goal. (Vascular overlap routes to the Peripheral Vascular reference.)
Model normal 2
Post-axillary-node-dissection care: the surgical site clean, the drain (if present) patent with decreasing output, the affected arm protected and mobilized per order, and no cellulitis signs. Skilled post-operative surveillance and limb protection required; supports Section I and the goal.
