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-stroke dysphagia, safe on the current plan: the resident taking the ordered mechanically altered diet (IDDSI Level 5) with nectar-thick liquids using aspiration precautions (upright, small bites, chin tuck), no coughing or wet voice with meals, and intake adequate. Licensed swallowing assessment and management of the aspiration-precaution and diet plan required to prevent aspiration pneumonia; a daily skilled need at SNF level. Supports Section K and the swallowing care-plan goal; SLP swallow-plan carryover ongoing. (Intake/diet detail routes to the Nutrition reference.)
Model normal 2
Diet-texture progression after a swallow re-evaluation: advanced from puree to a mechanically altered diet per the SLP recommendation, tolerating without coughing or wet voice, precautions maintained. Skilled management of the safe diet progression and aspiration surveillance required; supports Section K and the goal.
