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
Chronic venous insufficiency with compression therapy: bilateral lower-extremity edema improved to 1+ (from 2+) with the ordered compression applied correctly and elevation, pedal pulses palpable, skin with hemosiderin staining but intact (no new breakdown), no calf tenderness or asymmetry. Licensed vascular assessment and skilled application/evaluation of compression required to reduce edema and prevent ulceration; a daily SNF-level need. Supports Section J and the vascular care-plan goal.
Model normal 2
Peripheral arterial disease monitoring: the affected foot with palpable/dopplerable pulses per baseline, warm with intact color and brisk capillary refill, no rest pain or new skin change, protective foot care in place. Skilled perfusion assessment required to detect ischemic change; supports Section I and the vascular goal.
