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 |
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COPD-exacerbation recovery day 4: respiratory rate 20 with pursed-lip breathing at rest and no accessory-muscle use, SpO₂ 90% on 2 L within the ordered 88–92% target, lungs with scattered expiratory wheeze improved from diffuse, cough now productive of scant clear sputum (was purulent), tolerating the scheduled bronchodilator and the steroid taper. Licensed observation required to detect a recurring exacerbation and to evaluate the response to treatment and the oxygen order; the potential for respiratory change makes daily skilled monitoring necessary at SNF level. Supports the Section O oxygen/treatment items and the respiratory care-plan goal. |
Model normal 2 |
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Inhaler-technique teaching to competence: return-demonstration of the metered-dose inhaler with a spacer 5/5 on the second attempt after correction of the actuation timing, and the symptom-action plan (green/yellow/red) teach-back 100%. Skilled instruction required because incorrect technique undermines therapy and drives readmission; a covered skilled service reinforced daily toward discharge. Supports the respiratory goal. |