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. Licensed monitoring and administration required to interpret the trend, apply the correction scale 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 endocrine care-plan goal; regimen continued.
Model normal 2
New insulin start, titration day 3: glucose trend improving (fasting 210 → 156 over three days) on the titrating basal dose per the order, no hypoglycemia, teaching of self-administration ongoing. Skilled titration, monitoring, and teaching required to reach glycemic targets safely; supports Section N and the endocrine goal.
