| Scale | Label | Description |
| +4 | Combative | Combative, violent , immediate danger to staff |
| +3 | Very agitated | Pulls to remove tubes or catheters; aggressive |
| +2 | Agitated | Frequent non-purposeful movement, fights ventilator |
| +1 | Restless | Anxious, apprehensive, movement, not aggressive |
| 0 | Alert and calm | Spontaneously pays attention to caregiver |
| −1 | Drowsy | Not fully alert, but has sustained awakening to voice (eye opening and contact >10 sec) |
| −2 | Light sedation | Briefly awakens to voice (eyes open and contact < 10 sec) |
| −3 | Moderate sedation | Movement or eye opening to voice (no eye contact) |