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
Weekly skin assessment: skin intact over all bony prominences, Braden 16 (moderate risk), repositioning q2h and the pressure-redistribution surface in use per the plan, heels floated, incontinence care timely — RN surveillance confirms no new pressure injury and supports the Section M ‘no pressure ulcer’ coding and the skin care-plan goal; prevention plan continued.
Model normal 2
Stage 3 sacral pressure injury, ordered sterile dressing change performed: wound bed 75% granulation (up from 60% last week), scant serous exudate, periwound intact, no odor, measurements 3.0 × 2.2 × 0.3 cm (down from 3.4 × 2.6 × 0.4). Skilled procedure and healing-trajectory assessment required; supports Section M healing and the skin goal.
