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
ESRD on hemodialysis, non-dialysis day: the AV fistula with a palpable thrill and audible bruit and the access limb protected (no BP or venipuncture), weight and volume status consistent with the dry-weight target, no uremic or fluid-overload symptoms, on the renal diet and phosphate binder per order, and the next session coordinated with the unit. Licensed access and volume assessment and dialysis coordination required; the potential for a rapid fluid-electrolyte change makes daily skilled observation necessary at SNF level. Supports the Section O dialysis item and the renal care-plan goal.
Model normal 2
Post-hemodialysis assessment: tolerated the treatment without intradialytic hypotension or cramping, the access site without bleeding, weight at the post-dialysis target, blood pressure stable, and no disequilibrium symptoms; medications timed around dialysis per order. Skilled post-dialysis observation and access assessment required; supports the Section O item and the goal.
