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
Psychosocial factors supporting recovery this shift: mood stable on the current plan (PHQ trend improving), engaged and motivated, participating fully in the skilled rehabilitation and ADL program; support system involved and discharge caregiver identified. Licensed management and evaluation required to keep the psychosocial factors from undermining the skilled goals and to coordinate the discharge plan; on this stay that integration is part of the daily skilled need. Supports Section D/Q and the psychosocial care-plan goal.
Model normal 2
Caregiver teaching toward a safe discharge: the daughter (the discharge caregiver) taught the transfer technique and the medication schedule with a return-demonstration 8/8 on the second attempt and teach-back of the warning signs 100%. Skilled instruction of the caregiver to competence required for a safe discharge — a covered skilled service reinforced across sessions. Supports the discharge-planning goal (Section Q).
