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-hysterectomy day 3: minimal expected vaginal spotting (no heavy bleeding or clots), the abdominal incision clean and dry with staples intact and no surrounding erythema, no fever, tolerating diet with bowel sounds present, VTE prophylaxis given, and activity per the surgeon’s order. Licensed post-operative surveillance for hemorrhage, cuff dehiscence, infection, and VTE required; a daily skilled need. Supports Section I and the care-plan goal. (VTE prophylaxis routes to the Anticoagulation overlay.)
Model normal 2
Pessary management: the pessary in place with a comfortable fit, the vaginal/perineal skin intact without erosion or discharge, and cleaning/care per the ordered schedule. Skilled pessary assessment and care required to maintain fit and prevent erosion; supports Section I and the goal.
