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-cataract-extraction day 3: the operative eye white and quiet with no abnormal discharge, mild expected scratchiness only, the ordered eye-drop regimen (an antibiotic and a steroid on the ordered taper) administered with correct technique, the shield in place for sleep, and vision improving per the resident. Licensed administration of the ophthalmic regimen and observation for a post-operative complication required; a covered daily skilled service at SNF level. Supports the Section B vision item and the eye care-plan goal; teaching of self-administration ongoing.
Model normal 2
Post-retinal-repair positioning day 2: the required face-down positioning maintained per the surgeon’s order with the resident’s tolerance and skin monitored, the eye-drop regimen administered, and the operative eye without new pain or discharge. Skilled enforcement and evaluation of the positioning order and the drop regimen required to protect the repair; supports the eye goal.
