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
PICC-line care with IV antibiotic, day 5 of therapy: the medication administered through the PICC over the ordered time per order, brisk blood return, the site without erythema, swelling, or drainage, the dressing clean/dry/intact and dated, the line flushed per protocol, and the infusion tolerated without reaction. Licensed administration and line assessment required for the central route and for early recognition of a complication; a covered daily skilled procedure at SNF level. Supports the Section O IV-medication item and the infection care-plan goal.
Model normal 2
Surgical drain (Jackson-Pratt), post-operative: the drain patent with serosanguineous output of decreasing volume (down from the prior shift), the site clean without erythema, the bulb compressed to suction, and the drain secured. Skilled assessment of drain output and site and management of the closed drainage system required; supports the Section update and the post-surgical care-plan goal.
