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
Sleep-disordered breathing on CPAP, tolerating this shift: CPAP applied at the ordered pressure with a good mask seal, worn through the night, no observed apneas and SpO₂ maintained per the ordered range, and the resident reporting restful sleep and participating in the daytime program. Licensed set-up, monitoring, and troubleshooting of the device required, and observation for a sleep-related respiratory change; a daily skilled service at SNF level. Supports the Section O device item and the sleep care-plan goal; adherence teaching ongoing.
Model normal 2
Sleep supporting recovery: an adequate, consolidated sleep-wake pattern with pain and dyspnea controlled overnight and the resident rested and engaged in the skilled program by day. Skilled management to keep sleep from undermining participation required; supports the goal.
