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
Diabetes with insulin management: fasting glucose 128 and pre-dinner 146 within the ordered range on a basal-bolus regimen with correction per the ordered scale, no hypo- or hyperglycemic symptoms, intake consistent with the plan, feet intact with protective care in place. Licensed monitoring and administration required to interpret the trend, apply the correction with judgment, and recognize early hypo/hyperglycemia; the potential for glycemic change makes daily skilled observation necessary at SNF level. Supports the Section N insulin day and the diabetes care-plan goal; regimen continued.
Model normal 2
New insulin start, titration day 3: the fasting trend improving (210 → 156 over three days) on the titrating basal dose per order, no hypoglycemia, self-administration teaching ongoing with return-demonstration progressing. Skilled titration, monitoring, and teaching required to reach targets safely; supports Section N and the diabetes goal.
