5. Abnormal findings

Abnormal findings and what they may signal — each warrants Mode B focused documentation and, where parameters are met, intervention and notification:

• Depressed mood, anhedonia, or neurovegetative symptoms — a positive depression screen.
• Elevated anxiety — a positive anxiety screen.
• Thoughts of self-harm — which trigger an immediate risk assessment and safety response (Section 12).
• Thoughts of harm to others — which trigger an immediate safety response per protocol.
• Psychotic symptoms (hallucinations, delusions, or paranoia), manic symptoms, or severe agitation.
• Psychiatric-medication nonadherence or significant side effects.
• A substance-use concern.
• An acute behavioral change (evaluate for a medical or delirium cause) with a functional or safety impact.