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
Post-pneumonia day 4: lungs with decreasing right-base crackles, RR 20 unlabored, SpO₂ 94% on 2 L per the ordered parameter, afebrile, no accessory-muscle use, cough now productive of scant clear sputum (was thick yellow). Licensed observation required to detect early re-deterioration and to evaluate the response to the resolving infection and the O₂ order; the potential for rapid respiratory change makes daily skilled monitoring necessary, available only in this SNF. Supports the Section O oxygen day and the respiratory care-plan goal; skilled observation continues daily.
Model normal 2
Tracheostomy care per order: suctioned scant white secretions, airway clear post-suction, breath sounds equal, stoma site without erythema or drainage, ties secure, SpO₂ 96% on the ordered setting. Skilled aspiration and airway assessment required to maintain airway patency and detect complications; a covered daily skilled procedure at SNF level. Supports the Section O tracheostomy/suctioning items and the airway care-plan goal.
