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
Warfarin management: INR 2.4 within the target range of 2.0–3.0, the dose continued per the protocol, no bleeding signs (no bruising, epistaxis, hematuria, or melena), and no new interacting medications or major vitamin-K dietary change. Licensed interpretation of the INR with protocol-based dosing and daily bleeding surveillance required; the narrow therapeutic window makes daily skilled monitoring necessary at SNF level. Supports the Section N anticoagulant day and the anticoagulation care-plan goal.
Model normal 2
DOAC management: the direct oral anticoagulant administered per order with renal function stable on the last lab, no bleeding signs, and fall precautions in place; adherence and interacting medications reviewed. Skilled bleeding surveillance and renal/adherence monitoring required; supports Section N and the goal.
