- Degree of agitation (how agitated is the patient?)
- https://onlinelibrary.wiley.com/doi/full/10.1002/emp2.12138 (image below)

3. Assessment Scales
a. Positive and Negative Syndrome Scale (PANSS-EC)
- Evaluates five items: excitement, tension, hostility, uncooperativeness, and poor impulse control
- Score: Ranges from 5 to 35
- ≥ 20 clinically correspond to severe agitation
b. Altered Mental Status Scale (AMSS)
- Scale ranges from unresponsive to combative
c. Behavioral Activity Rating Scale (BARS)
1. Difficult or unable to rouse |
2. Asleep, but responds normally to verbal or physical contact |
3. Drowsy, appears sedated |
4. Quiet and awake (normal level of activity) |
5. Signs of overt (physical or verbal) activity, calms down with instructions |
6. Extremely or continuously active, not requiring restraint |
7. Violent, requires restraint |