5. Abnormal findings

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

• Disorientation to time, place, person, or situation.
• Recent or remote memory impairment.
• Inattention or impaired concentration.
• Impaired executive function, judgment, or problem-solving.
• An altered or fluctuating level of consciousness.
• An acute onset or a fluctuating course (a delirium concern — urgent) versus a chronic, progressive decline (dementia).
• Cognitive impairment that compromises safety, medication management, or decision-making capacity, with behavioral and psychological symptoms.
• A new or worsening change from the patient's baseline.