Respiratory Rate (breaths per minute)

RR ≤ 8 (severe bradypnea / respiratory depression)+3RR 9–11 (mildly low)+1RR 12–20 (normal)+0RR 21–24 (mildly elevated)+2RR ≥ 25 (significant tachypnea — high-risk)+3

Oxygen Saturation (SpO2) — Scale 1 (standard patients)

Scale 1: SpO2 ≤ 91% (severe hypoxemia)+3Scale 1: SpO2 92–93% (mild-moderate hypoxemia)+2Scale 1: SpO2 94–95% (borderline)+1Scale 1: SpO2 ≥ 96% (normal)+0

Supplemental Oxygen

No — breathing room air+0Yes — receiving supplemental oxygen (any delivery device)+2

Temperature (°C)

Temperature ≤ 35.0°C (hypothermia)+3Temperature 35.1–36.0°C (mild hypothermia)+1Temperature 36.1–38.0°C (normal)+0Temperature 38.1–39.0°C (fever)+1Temperature ≥ 39.1°C (high fever)+2

Systolic Blood Pressure (mmHg)

SBP ≤ 90 mmHg (hypotension / possible shock)+3SBP 91–100 mmHg (borderline low)+2SBP 101–110 mmHg (low-normal)+1SBP 111–219 mmHg (normal range)+0SBP ≥ 220 mmHg (extreme hypertension)+3

Heart Rate (beats per minute)

HR ≤ 40 bpm (severe bradycardia)+3HR 41–50 bpm (bradycardia)+1HR 51–90 bpm (normal)+0HR 91–110 bpm (mild tachycardia)+1HR 111–130 bpm (moderate tachycardia)+2HR ≥ 131 bpm (severe tachycardia)+3

Level of Consciousness (ACVPU Scale)

A — Alert (awake, oriented, at baseline mental status)+0C — New Confusion or acute delirium (change from baseline)+3V — Responds to voice but not alert+3P — Responds to pain only+3U — Unresponsive (no response to voice or pain)+3

National Early Warning Score (NEWS 2)

National Early Warning Score (NEWS 2)