1. NO RESPONSE
   Patient appears to be in a deep sleep and is completely unresponsive to any stimuli presented to him.
2. GENERALIZED RESPONSE
   Patient reacts inconsistently and non-purposefully to stimuli in a non-specific manner. Responses are limited in nature and are often the same regardless of stimulus presented. Responses may be physiological changes, gross body movements and vocalization. Responses are likely to be delayed. The earliest response is to deep pain.
3. LOCALIZED RESPONSE
   Patient reacts specifically but inconsistently to stimuli. Responses are directly related to the type of stimulus presented, as in turning head toward a sound or focusing on an object presented. The patient may withdraw an extremity and vocalize when presented with a painful stimulus. He may follow simple commands in an inconsistent, delayed manner, such as closing his eyes, squeezing or extending an extremity. Once external stimuli are removed, he may lie quietly. He may also show a vague awareness of self and body by responding to discomfort by pulling at nasogastric tube catheter or resisting restraints. He may show a bias toward responding to some persons, especially family and friends, but not to others.
4. CONFUSED-AGITATED
   Patient is in a heightened state of activity with severely decreased ability to process information. He is detached from the present and responds primarily to his own internal confusion. Behavior is frequently bizarre and non-purposeful relative to his immediate environment. He may cry out or scream out of proportion to stimuli even after removal, may show aggressive behavior, attempt to remove restraints or tube or crawl out of bed in a purposeful manner. He does not discriminate among persons or objects and is unable to cooperate directly with treatment efforts. Verbalization is frequently incoherent or inappropriate to the environment. Confabulation may be present; he may be hostile. Gross attention to environment is very brief and selective attention often nonexistent. Being unaware of present events, patient lacks short-term recall and may be reacting to past events. He is unable to perform self-care activities without maximum assistance. If not disabled, he may perform automatic motor activities such as sitting, reaching and ambulating as part of his agitated state but not as a purposeful act, or on request, necessarily.
5. CONFUSED-INAPPROPRIATE
   Patient appears alert and is able to respond to simple commands fairly consistently. However, with increased complexity of commands or lack of any external structure, responses are non-purposeful, random, or at best, fragmented toward any desired goal. He may show agitated behavior but not on an internal basis, as in level IV, but rather as a result of external stimuli and usually out of proportion to the stimulus. He has gross attention to the environment, is highly distractable and lacks ability to focus attention to a specific task without frequent redirection. With structure, he may be able to converse on a social-automatic level for short periods of time. Verbalization is often inappropriate; confabulation may be triggered by present events. Memory is severely impaired, with confusion of past and present in reaction to ongoing activity. Patient lacks initiation of function tasks and often shows inappropriate use of objects with external direction. He may be able to perform previously learned tasks when structured for him but is unable to learn new information. He responds best to self, body, comfort and often, family members. The patient can usually perform self-care activities with assistance and may accomplish feeding with supervision. Management on the unit is often a problem if the patient is physically mobile as he may wander off, either randomly or with vague intention of "going home".
6. CONFUSED-APPROPRIATE
   Patient shows goal-directed behavior, but is dependent on external input for direction. Response to discomfort is appropriate and is able to tolerate unpleasant stimuli, eg., NG tube when need is explained. He follows simple directions consistently and shows carryover for tasks he has learned; eg., self care. He is at least supervised with old learning; unable to maximally assisted for new learning with little or no carryover. Responses may be incorrect due to memory problems but are appropriate to the situation. They may vary from delayed to immediate and he shows increased ability to process information with little or no anticipation or prediction of events. Past memories show more depth and detail than recent memory. The patient may show beginning awareness of his situation by realizing he doesn't know an answer. He no longer wanders and is inconsistently oriented to time and place. Selective attention to tasks may be impaired, especially with difficult tasks and in unstructured settings, but is now functional for common daily activities. He may show vague recognition of some staff and has increased awareness of self, family and basic needs.
7. AUTOMATIC-APPROPRIATE
   Patient appears appropriate and oriented within hospital and home settings, goes through daily routine automatically but robot-like, with minimal to absent confusion and has shallow recall for what he has been doing. He shows increased awareness of self, body, family, food, people and interaction in the environment. He has superficial awareness of but lacks insight into his condition, decreased judgment and problem solving and lacks realistic planning for his future. He shows carryover for new learning at a decreased rate. He requires at least minimal supervision for learning and safety purposes. He is independent in self-care activities and supervised in home and community skills for safety. With structure, he is able to initiate tasks or social and recreation activities in which he now has interest. His judgment remains impaired. Pre-vocation evaluation and counseling may be indicated.
8. PURPOSEFUL-APPROPRIATE
   Patient is alert and oriented, is able to recall and integrate past and recent events and is aware of and responsive to his culture. He shows carryover for new learning if acceptable to him and his life role and needs no supervision once activities are learned. Within his physical capabilities he is independent in home and community skills. Vocational rehabilitation, to determine ability to return as a contributor to society, perhaps in a new capacity, is indicated. He may continue to show decreases relative to pre-morbid abilities in quality and rate of processing, abstract reasoning, tolerance for stress and judgment in emergencies or unusual circumstances. His social, emotional and intellectual capacities may continue to be a decreased level for him, but functional within society.

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