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
Pain assessed at 2/10 at rest and controlled on the scheduled regimen, no effect on participation or sleep; PAINAD used as the resident has advanced dementia (score 1 — occasional negative vocalization only) — RN monitoring confirms adequate control against the ordered plan and supports the Section J pain items and the comfort care-plan goal; regimen continued.
Model normal 2
Post-operative pain controlled: scheduled analgesic given with breakthrough available, pain 3/10 with movement (down from 6/10), participating in therapy, sleeping through the night; opioid with a bowel regimen in place, no oversedation (RASS 0), respirations 16 — RN assessment confirms effective, monitored pain control; supports Section J/N and the pain goal.
