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
New-ostomy care, post-colostomy day 5: stoma beefy-red and viable, budded and draining soft brown effluent of adequate volume, peristomal skin intact without erythema, appliance seal secure and changed per schedule; teaching of self-care ongoing with the resident. Licensed assessment of stoma viability and peristomal skin and skilled ostomy care and teaching required; a daily SNF-level need. Supports the Section H ostomy item and the GI care-plan goal.
Model normal 2
Post-GI-bleed observation day 3: no recurrent melena or hematochezia, vital signs stable (no tachycardia or orthostasis), no pallor, hemoglobin stable on the last lab, tolerating the ordered diet. Skilled observation required to detect re-bleeding and evaluate recovery; the potential for a further acute episode makes daily skilled monitoring necessary at SNF level. Supports Section I and the GI goal.
