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
Perineal skin protection in the incontinent, dependent resident: the perineal and genital skin intact with the moisture-barrier/containment plan in place, prompt cleansing after incontinence, pressure offloading and repositioning per plan, and no erythema, denudement, or breakdown. Licensed perineal skin assessment and specialized moisture/pressure management required, because this resident is at high risk for perineal breakdown; a daily skilled need. Supports Section M and the care-plan goal. (Wound staging routes to the Skin reference.)
Model normal 2
Complex perineal wound care: the perineal/sacral wound cleansed and dressed per the ordered regimen with the periwound skin protected, the wound characteristics assessed and trended, and containment managed to keep the wound clean; no signs of spreading infection. Skilled complex wound care and assessment required; supports Section M and the goal.
