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-sepsis (urosepsis) recovery day 4 on IV antibiotics: the resident afebrile with the heart rate and blood pressure normalized and stable versus the septic peak, mentation returning toward baseline, intake improving, the IV antibiotic administered per order through a patent line with the source (a treated UTI) resolving, and no new systemic signs. Licensed systemic surveillance for recurrence, administration and monitoring of the IV antibiotic, and management of the fragile recovery required; the potential for a return of instability makes daily skilled observation necessary at SNF level. Supports Section I/O/N and the care-plan goal. (The urinary source routes to the Continence reference.) |
Model normal 2 |
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Sepsis surveillance in a high-risk resident: an at-risk resident (recent infection, indwelling device) monitored with parameter-based vitals and a mentation check, afebrile with no early sepsis signs, and the device/source assessed. Skilled early-sepsis surveillance required, because early recognition is time-critical; supports Section I and the goal. (The systemic view routes to the General/Constitutional reference.) |