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-event blood-pressure management: BP 138/82 and heart rate 70 within the ordered parameters, no orthostatic drop on standing, no headache or visual change, tolerating the antihypertensive regimen without lightheadedness or falls. Licensed assessment required to apply the hold/give parameters with judgment and to detect uncontrolled hypertension or over-treatment; on this post-acute stay the parameter-based BP management contributes to the daily skilled need. Supports Section N and the cardiovascular care-plan goal.
Model normal 2
Antihypertensive titration day: the agent increased per the order with BP moving toward target (from 158/90 to 142/84) and tolerated without orthostasis, self-management teaching (BP goals, adherence, orthostatic-safety) reinforced with teach-back. Skilled titration and tolerance monitoring required; supports Section N and the goal.
