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
Toileting program followed q2h with continence maintained this shift, no indwelling catheter (none medically indicated), skin dry and intact in the perineal area, no dysuria or foul urine — RN confirms the individualized program is effective (F690) and supports the Section H continence item and the continence care-plan goal.
Model normal 2
Indwelling catheter present for a documented medical indication (stage 4 sacral wound requiring urinary diversion for healing): catheter patent and draining clear yellow urine, secured, site clean, closed system intact, output adequate — RN care and daily necessity review required; CAUTI-prevention measures in place; supports Section H and the care-plan goal.
