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
Cognitive status at the documented baseline: the resident with moderate dementia is oriented to self and place per baseline, attention consistent with baseline across the shift, no acute fluctuation, no new agitation, participating in care with the usual cueing. Licensed assessment required to distinguish the chronic baseline from a new delirium and to detect an early acute change; on this stay the cognitive surveillance is part of the daily skilled need. Supports Section C and the care-plan goal.
Model normal 2
Post-delirium recovery: mental status returning toward the baseline (attention improved, fluctuation resolving) after treatment of the precipitating infection, oriented with cueing, no new safety events. Skilled observation required to confirm resolution and detect recurrence; supports Section C and the goal.
