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
Post-stroke expressive aphasia, communication method working this shift: the resident uses a communication board and yes/no reliably, understands others well (receptive intact), and — with the board and extra time — participated in the skilled therapy and ADL program and reported needs, including a pain check. Licensed management of the deficit and reinforcement of the method required to keep the resident participating and able to report a change; on this stay that is part of the daily skilled need. Supports Section B and the communication care-plan goal; method reinforcement and SLP carryover ongoing.
Model normal 2
Post-tracheostomy communication: the resident using a writing board and mouthing with staff, a reliable call-signal established given the inability to call out verbally, and understanding intact. Skilled establishment and reinforcement of a safe communication and call method required — a safety-critical skilled service for a resident who cannot vocalize. Supports Section B and the goal.
