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
Blood transfusion for symptomatic anemia: the ordered packed-red-cell unit administered after the two-person identity/consent check, baseline and interval vital signs stable with no transfusion-reaction signs (no fever, chills, dyspnea, back pain, or rash), the unit infused within the ordered time, and post-transfusion vitals and hemoglobin per order. Licensed administration and reaction surveillance required for the transfusion — a covered skilled procedure at SNF level. Supports the Section O transfusion item and the care-plan goal. (Access detail routes to the Lines/Drains/Devices reference.)
Model normal 2
Neutropenia with precautions: the resident on neutropenic precautions per the low absolute neutrophil count, afebrile with no infection signs, protective measures in place (hand hygiene, avoidance of exposure), and counts monitored per order. Skilled infection surveillance and neutropenic-precaution management required, because a fever may be the only sign of a life-threatening infection; supports Section O/I and the goal.
