Patient appears to be in a deep sleep and is completely unresponsive to any stimuli presented to him.

LEVEL II

Patient reacts inconsistently and non-purposefully to stimuli in a nonspecific manner. Responses are limited in nature and are often the same regardless of stimulus presented. Responses may be physiological changes, gross body movements, and vocalizations. Responses are likely to be delayed. The earliest response is to deep pain.

LEVEL III

Patient reacts specifically but inconsistently to stimuli. Responses are directly related to the type of stimulus presented, as in turning the 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, or 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 or catheter, or by resisting restraints. He may show a bias toward responding to some persons, especially family and friends, but not to others.

LEVEL IV

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 nor 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 physically, he may perform automatic motor activities such as sitting, reaching, and ambulating as part of his agitated state but not as a purposeful act nor on request, necessarily.

LEVEL V

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 distractible, 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; and 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 functional tasks and often shows inappropriate use of objects without 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 to family members. The patient usually can 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.

LEVEL VI

Patient shows goal-directed behavior, but is dependent on external input for direction. Response to discomfort is appropriate and he is able to tolerate unpleasant stimuli, e.g. NG tube, when need is explained. He follows simple directions consistently and shows carryover for tasks he has learned; e.g., self-care. He is at least supervised for old learning; unable to maximally be assisted for new learning with little or no carryover. Responses may be incorrect due to memory problems but are appropriate to the situation. Responses may be delayed to immediate and patient shows decreased ability to process information with little or no anticipation or prediction of events. Past memory show more depth and detail than recent memory. The patient may show beginning to immediate awareness of situation by realizing he doesn't know an answer. He no longer wanders and is inconsistently oriented to time and placed. Selective attention to tasks may be impaired especially with difficult tasks and in unstructured settings, but is now functional for common daily activities (30 minutes with structure). He may show a vague recognition of some staff, has increased awareness of self, family, and of basic needs (as food), again in an appropriate manner as in contrast to Level V.

LEVEL VII

Patient appears appropriate and oriented within hospital and home settings, goes through daily routine automatically, but frequently robot-like, with minimal to absent confusion, but has shallow recall of what he has been doing. He shows increased awareness of self, body, family, foods, people, and interaction of 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, but at a decreased rate. He requires at least minimal supervision for learning and for 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 as social or recreational activities in which he now has an interest. His judgment remains impaired; such that he is unable to drive a car. Prevocational or avocational evaluation and counseling may be indicated.

LEVEL VIII

Patient is alert, oriented, and 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 premorbid 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 at a decreased level for him, but functional within society.