This scaling should be done twice daily and nursing staff should be well trained to perform .Here the nurse can scale the specified targeted mental function along the day.

 

 

 

 

Knows where he is	yes = 10	no = 0
Knows surroundings

 

 

 

Short phrases	yes = 10	no= 0
Has usual speech
Refuses to speak
Takes part in conversations

 

 

 

 

Laughs and smiles while he is sitting alone	yes	no
Laughs and smiles at funny comments
Looks sad
Says that he is depressed

 

 

Hears things that are not there	yes	no
Talks to himself
Sees things that are not there