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
Post-craniotomy day 6: the scalp incision well-approximated with staples intact, no drainage, surrounding skin without erythema or swelling, and — with the neuro exam — alert and oriented at baseline, no headache beyond the expected, no nausea, pupils equal and reactive. Licensed incision care and neurological surveillance required to detect a post-surgical complication (bleeding, infection, raised pressure); a daily skilled need at SNF level. Supports Section I and the care-plan goal; the full neuro exam is documented in the Neurological reference.
Model normal 2
Post-fall head-strike surveillance day 2 (no anticoagulant, no injury on survey): scalp intact without new hematoma, neuro checks per protocol within normal limits, no headache, vomiting, or drowsiness. Skilled post-head-injury surveillance required to detect a delayed complication; supports the care-plan goal. (The post-fall protocol is documented in the Falls reference.)
