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 |
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Post total-knee-replacement day 6: incision well-approximated, staples intact, no drainage or surrounding erythema, mild expected swelling improving with elevation and ice per order; operative-limb neurovascular status intact (warm, pulses present, sensation and movement intact, brisk capillary refill); weight-bearing as tolerated with the surgeon’s precautions observed; pain 3/10 with movement (down from 6/10), participating fully in therapy; VTE prophylaxis administered. Licensed post-surgical assessment required to detect infection, bleeding, VTE, and neurovascular compromise and to support the rehabilitation plan; a daily SNF-level need. Supports Section GG/O/N and the rehabilitation care-plan goal. |
Model normal 2 |
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Post hip-fracture ORIF, rehabilitation-nursing carryover: transfers and ambulation performed with the ordered assist and the hip precautions maintained, restorative reinforcement of the therapy program delivered with a CNA return-demonstration, pain controlled to allow participation, incision intact. Skilled evaluation of the post-surgical rehabilitation plan and safe carryover required; supports Section GG and O0500 and the functional goal. |