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-stroke rehabilitation day 8, carryover across deficits: left-sided weakness improving (left arm 4/5 from 3/5), rehabilitation-nursing reinforcement of the therapy program delivered with a CNA return-demonstration, swallowing safe on the ordered texture with aspiration precautions, communication effective with the established method, and secondary prevention in place (blood pressure at the ordered goal, the antiplatelet/anticoagulant given with no bleeding signs, the statin continued). Licensed rehabilitation nursing, secondary-prevention management, and complication surveillance required to advance recovery and prevent readmission; a daily skilled need. Supports Section GG/C/N and the stroke care-plan goal. |
Model normal 2 |
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Secondary-prevention and complication surveillance day: blood pressure at the ordered post-stroke goal, the anticoagulant for the cardioembolic stroke given with bleeding surveillance, no aspiration or DVT signs, mood screened with support in place, and no new deficit. Skilled management and surveillance required; supports Section N and the goal. (Anticoagulation detail routes to the Anticoagulation overlay.) |