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
Diabetic peripheral neuropathy, protective management this shift: reduced protective sensation in a stocking distribution of both feet (diminished monofilament per the last exam), the feet inspected and intact with no unnoticed injury, protective footwear and pressure-offloading in place, and no burns or trauma. Licensed sensory assessment and active protective management required, because the loss of protective sensation puts the resident at risk for unnoticed injury and pressure breakdown; a daily skilled need. Supports Section GG and the care-plan goal. (Foot-wound detail routes to the Skin reference; diabetic detail to the Diabetes overlay.)
Model normal 2
Post-stroke sensory loss, safe: reduced sensation on the affected side with the skin inspected and intact, positioning and protection of the affected limb per plan, and safe mobility with the deficit accounted for. Skilled sensory assessment and protective management required to prevent injury to the insensate side; supports Section GG and the goal. (The neuro exam routes to the Neurological reference.)
