Clinical Scales
APGAR
Sign
0
1
2
A
ppearance (color)
Blue or pale
Pink body with blue extremities
Completely pink
P
ulse (heart rate)
Absent
Slow (<100/min)
>100/min
G
rimace (reflex irritability)
No response
Grimace
Cough or sneeze
A
ctivity (muscle tone)
Limp
Some flexion
Active movement
R
espirations
Absent
Slow, irregular
Good, crying
Total APGAR Score:
Glasgow Coma Scale (GCS)
Parameter
Response
Score
Eyes
Open
Spontaneously
4
To verbal command
3
To pain
2
No response
1
Best motor response
To verbal command
Obeys
6
To painful stimulus
Localizes pain
5
Flexion-withdrawal
4
Decorticate (flex)
3
Decerebrate (extend)
2
No response
1
Best verbal response
Oriented, converses
5
Disoriented, converses
4
Inappropriate responses
3
Incomprehensible sounds
2
No response
1
Total GCS Score:
Mini Mental Status Exam (MMSE)
Category
Question
Score
Orientation
What is the
year
?
1 point if correct:
What is the
season
?
1 point if correct:
What is the
date (#)
?
1 point if correct:
What is the
weekday
?
1 point if correct:
What is the
month
?
1 point if correct:
What
state
are you in?
1 point if correct:
What
county
are you in?
1 point if correct:
What
town
are you in?
1 point if correct:
What
building
are you in?
1 point if correct:
What
floor
are you on?
1 point if correct:
Registration
Name 3 objects: 1 second to say each. Then ask the patient all 3 after you have said them. Give 1 point for each correct answer. Then repeat until all 3 are learned.
None registered:
One registered:
Two registered:
Three registered:
Attention & Calculation
Serial 7's - starting with 100, subtract 7 repeatedly. Stop after 5 answers. Alternatively, spell "WORLD" backward.
93 / D
86 / L
79 / R
72 / O
65 / W
Recall
Ask for the three objects named above. Give one point for each correct answer.
None recalled:
One recalled:
Two recalled:
Three recalled:
Language
Point to a pencil and have the patient name it.
1 point if correct:
Point to a watch and have the patient name it.
1 point if correct:
Have the patient repeat the phrase "No if's, and's, or but's."
1 point if correct:
Have the patient follow a three-stage command: Take a paper in your right hand, fold it in half, and put it on the floor."
No stages followed:
1 stage followed:
2 stages followed:
3 stages followed:
Give the patient a piece of paper with the following instructions on it, and ask the patient to read and obey the instructions.
Close your eyes.
Write a sentence.
Copy this design.
No commands followed:
1 command followed:
2 commands followed:
3 commands followed:
Total MMSE Score:
Subscores:
Orientation:
Registration:
Attention & Calculation:
Recall:
Language:
APGARGlasgow Coma Scale (GCS)Mini Mental Status Exam (MMSE)