New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 60 - HOME CARE SERVICES
Appendix B
Universal Citation: NJ Admin Code B
Current through Register Vol. 56, No. 24, December 18, 2024
RANCHO SCALE
Level | Response | Patient Function |
I | No response | Patient is completely unresponsive to any |
stimulus. | ||
II | Generalized response | Patient reacts to the environment, but not as a |
specific response to the stimulus--responses | ||
are often the same despite change of stimuli. | ||
The earliest response is often gross movement | ||
to deep pain. | ||
III | Localized response | Patient reacts in a specific manner to the |
stimulus, but may inconsistently turn head to | ||
sound, withdraw an extremity to pain, squeeze | ||
fingers placed in the hand, or respond to | ||
family members more than others. | ||
IV | Confused, agitated | Patient is in a heightened state of activity, |
but is still severely detached from the | ||
surroundings. Internal confusion and very | ||
limited ability to learn is combined with short | ||
attention span and easy fatigue. The patient | ||
is unable to cooperate and may be aggressive, | ||
combative, or incoherent. | ||
V | Confused, inappropriate/ | Patient appears alert and is able to respond to |
nonagitated | simple commands. Responses are best with | |
familiar routines, people, and structured | ||
situations. Distractibility and short | ||
attention span lead to difficulty learning new | ||
tasks and agitation in response to | ||
frustrations. If physically mobile, there may | ||
be wandering. Much external structure is | ||
needed. Initiation and memory are limited. | ||
VI | Confused, appropriate | Patient shows goal-directed behavior, but still |
is dependent on external structure and | ||
direction. Simple directions are followed | ||
consistently and there is carry-over of | ||
relearned skills (like dressing), yet new | ||
learning progresses very slowly with little | ||
carry-over. Orientation is better and there is | ||
no longer inappropriate wandering. | ||
VII | Automatic, appropriate | Patient appears appropriate and oriented with |
familiar settings such as home and hospital, | ||
but is confused and often helpless in | ||
unfamiliar surroundings. The daily routine can | ||
be managed with minimal confusion as long as | ||
there are no changes. There is little recall | ||
of what has just been done. There is only a | ||
superficial understanding of the disability, | ||
with lack of insight into the significance of | ||
the remaining deficits. Judgment is impaired | ||
with inability to plan ahead. New learning is | ||
slow and minimal supervision is needed. | ||
Driving is unsafe; supervision is needed for | ||
safety in the community or in school and | ||
workshop settings. | ||
VIII | Purposeful, appropriate | Patient may not function as well as before the |
injury, but is able to function independently | ||
in home and community skills, including | ||
driving. Alert, oriented, and able to | ||
integrate past and present events. Vocational | ||
rehabilitation is indicated. Difficulties | ||
dealing with stressful or unexpected situations | ||
can arise, as there may be a decrease in | ||
abstract reasoning, judgment, intellectual | ||
ability, and tolerance of stress relative to | ||
premorbid capabilities. |
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