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
(A clean closed loop is this module’s ‘normal.’) Change identified (new low-grade fever and reduced intake), SBAR to the provider at 14:30 with vitals and the specific finding, orders received (labs, increased fluids) and carried out, responsible party notified at 14:45, monitoring set, a reassessment time documented, and SCSA criteria evaluated (not yet met — single self-limiting area) — the loop is closed and the record supports F580.
Model normal 2
Post-change monitoring day 2: the resident’s condition is trending back to baseline on the ordered interventions, vitals within parameters, intake improved — RN surveillance confirms resolution, the provider updated, the representative informed of the improvement, and the care plan reviewed; no SCSA required as the change was self-limiting.
