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
Fall-risk care plan in place and reviewed this shift: bed/chair alarm functioning, non-skid footwear on, call light in reach and answered promptly, scheduled toileting followed, bed low and locked — no fall this shift. RN reassessed risk because of the anticoagulant and a recent gait decline and confirms the individualized interventions remain in place (F689); ties to the care-plan falls goal. Skilled fall surveillance continues.
Model normal 2
Post-fall monitoring day 2 after a witnessed fall without injury: neuro checks completed per protocol and within normal limits, no new pain or functional change, gait reassessed with PT recommendations carried out. Licensed surveillance required to detect delayed injury and confirm the revised plan is effective; supports the Section J fall entry and the falls care-plan goal.
