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
Heart-failure recovery day 5: daily weight 151 lb, stable versus 151 lb yesterday and within 1 lb of the target, lungs clear, trace ankle edema improved from 2+, BP 122/74 within the ordered parameters, no orthostatic symptoms, tolerating activity. Licensed assessment required to correlate weight, edema, and lung findings with the diuretic and sodium orders and to detect early decompensation; the potential for rapid volume change makes daily skilled observation necessary at SNF level. Supports Section N/K and the cardiac care-plan goal; regimen continued.
Model normal 2
Post-cardiac-procedure recovery: apical rate 72 and regular, BP within parameters, procedure/access site intact without hematoma or bruit, no chest discomfort, tolerating progressive activity, on a monitored cardiac and anticoagulant regimen. Skilled observation and medication monitoring required to detect complications and evaluate the plan; supports Section N and the cardiac goal.
