By Miranda, Nursing Student (BSN candidate)

This guide is currently pending review by a licensed clinical nurse.

Last updated: April 25, 2026

How to Score and Document a RASS Assessment (Nursing Guide)

Your post-op patient is on a propofol drip with a target RASS of -2 to 0. The night nurse charted RASS -3 at 0400, and the intensivist on rounds wants to know whether the gtt should come down before extubation. I sat through this exact scenario in my critical-care rotation last semester. The framework that finally made it click is the three-step assessment, observe then voice then physical, scored top down from +4 to -5.

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Why This Matters

Regulatory bodies: Society of Critical Care Medicine (SCCM) - PADIS Guidelines, American Association of Critical-Care Nurses (AACN), The Joint Commission - Sedation and Anesthesia Care Standards, Vanderbilt ICU Delirium and Cognitive Impairment Study Group

The Richmond Agitation-Sedation Scale was developed by Sessler and colleagues at Virginia Commonwealth University in 2002 and validated for inter-rater reliability across 192 adult ICU encounters spanning medical and surgical, ventilated and nonventilated, sedated and unsedated patients. Ely and colleagues at Vanderbilt then confirmed reliability and validity in 275 mechanically ventilated patients in JAMA in 2003, and RASS has been the recommended ICU sedation tool ever since. The 2018 SCCM PADIS clinical practice guidelines (Devlin et al.) call for routine sedation monitoring with a validated tool in every adult ICU patient, and the Vanderbilt CIBS Center pairs RASS with CAM-ICU as the standard sedation-plus-delirium bedside protocol. From a documentation standpoint, the score drives titration of continuous sedatives like propofol and dexmedetomidine, the timing of spontaneous awakening trials (SAT), and the readiness assessment for spontaneous breathing trials (SBT). Charting RASS without the assessment method or the target band on a sedated patient is a survey finding and a common gap in ICU chart audits. Over-sedation contributes to longer ventilator days, ICU delirium, and post-ICU cognitive impairment; under-sedation drives self-extubation and accidental line removal. The score is small. The downstream decisions are not.
  1. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients — Sessler CN, Gosnell MS, Grap MJ, et al. Am J Respir Crit Care Med. 2002;166(10):1338-1344 (2002)
  2. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS) — Ely EW, Truman B, Shintani A, et al. JAMA. 2003;289(22):2983-2991 (2003)
  3. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS) — Devlin JW, Skrobik Y, Gelinas C, et al. Crit Care Med. 2018;46(9):e825-e873 (2018)
  4. Monitoring Delirium in the ICU - RASS and CAM-ICU implementation guidance — Vanderbilt ICU Delirium and Cognitive Impairment Study Group (CIBS Center) (2024)

What the Richmond Agitation-Sedation Scale Measures

RASS is a 10-point sedation and agitation scale ranging from -5 (unarousable) to +4 (combative), with 0 representing alert and calm. Sessler and colleagues developed it at Virginia Commonwealth University in 2002 to give ICU clinicians a single bedside scale that handled both sedation depth and agitation severity, replacing the patchwork of older scales like Ramsay (designed for sedation only) and SAS (designed for agitation only). The validation cohort spanned medical and surgical ICUs, intubated and nonintubated patients, and sedated and unsedated patients, which is why RASS is now recommended across every adult ICU population. RASS is not a delirium screening tool. It measures sedation depth and agitation level, but it does not detect inattention, disorganized thinking, or altered consciousness in the way CAM-ICU or ICDSC does. The two are paired in most ICUs: RASS first to determine arousability, then CAM-ICU only if the patient is at RASS -3 or higher. A CAM-ICU on a deeply sedated patient is uninterpretable because the patient cannot participate in attention testing. RASS is not validated for pediatric patients (use the State Behavioral Scale or Comfort-B), for procedural sedation (use the Modified Observer's Assessment of Alertness/Sedation, MOAA/S), or as a primary tool on general medical floors, though it is used informally on step-down units and PACUs.

The 10 Levels of RASS, Scored Top Down

Read the scale from +4 down to -5. The first descriptor that matches the patient indicates the score.

+4 Combative

Overtly combative or violent, immediate danger to staff. This is the patient who is swinging, kicking, or actively trying to harm caregivers. A +4 should trigger an immediate safety response (additional staff, restraints per order set, emergency medication per protocol) and a documented reassessment as soon as the patient is safe to approach.

+3 Very Agitated

Pulls at or removes tubes or catheters, aggressive behavior toward staff. Self-extubation risk is high at +3, and this score is the trigger many sedation protocols use to escalate continuous sedation or call the provider. Do not document +3 without naming the specific behavior you saw (which tube or line, which aggressive action) so the next nurse can validate the reassessment.

+2 Agitated

Frequent non-purposeful movement and fighting the ventilator (vent dyssynchrony). The patient does not show aggression toward staff but cannot stay still and is dyssynchronous with the vent. This score often triggers a sedation review or pain assessment, as vent dyssynchrony frequently indicates a pain or analgesia gap rather than a sedation gap.

+1 Restless

Anxious or apprehensive, but movements are not aggressive or vigorous. The patient may reposition frequently, pick at the sheets, or show facial signs of distress without acting out. +1 is the score where pain and anxiety drivers are easy to miss; document a CPOT or numeric pain score alongside RASS +1 if the patient cannot self-report.

0 Alert and Calm

Spontaneously pays attention to the caregiver, with eyes open, no agitation, and no sedation. Score 0 is the goal for most light-sedation strategies and marks the endpoint of a successful spontaneous awakening trial. Document 0 at the planned awakening hour, even if the patient drifts back to -1 within minutes; the chart must show that the SAT goal was reached.

-1 Drowsy

Not fully alert but sustains awakening (eye opening and eye contact) to voice for 10 seconds or longer. -1 falls within the recommended PADIS light-sedation band of -2 to 0 and is the score most ICUs target overnight for stable mechanically ventilated patients. The 10-second eye contact threshold separates -1 from -2 and is the most commonly mis-scored line on the scale.

-2 Light Sedation

Briefly awakens with eye contact to voice for under 10 seconds. The patient is responsive, but the response is shallow and short. -2 represents the lower bound of the PADIS light-sedation target. If the patient falls below this band when the team has ordered light sedation, decrease the continuous sedative.

-3 Moderate Sedation

Any movement or eye opening to voice, but no eye contact. The clinical line between -2 and -3 is eye contact, not duration alone. A patient who twitches a hand or briefly opens the eyes to voice without making eye contact scores -3, even if the movement was prompt. CAM-ICU remains valid at -3 because the patient is arousable to voice.

-4 Deep Sedation

No response to voice, but any movement or eye opening occurs with physical stimulation (shoulder shake or trapezius squeeze). Deep sedation is reserved for specific indications (refractory ICP, severe ARDS requiring neuromuscular blockade, status epilepticus); for most ICU patients, -4 is below target and prompts a sedation review. CAM-ICU is not valid at -4.

-5 Unarousable

No response to voice OR physical stimulation. -5 is the bottom of the scale and is uncommon outside of paralysis, deep sedation for status epilepticus, or true coma. A new -5 in a previously arousable patient is a clinical event, not a sedation reading; assess for over-sedation, neuro deterioration, or hemodynamic compromise and notify the provider.

The Three-Step Assessment Procedure

RASS is scored top down: you start by observing, escalate to voice if there is no observable score, and only escalate to physical stimulation if there is no response to voice. Step 1 is observation. Look at the patient at the bedside without speaking or touching. If the patient is overtly combative, very agitated, agitated, restless, or alert and calm, you have your score (+4 through 0) from observation alone. Step 2 is voice. If the patient appears asleep or unresponsive on observation, state the patient's name and ask the patient to open the eyes and look at you. The eye contact response gives you the score: sustained eye contact for 10 seconds or longer is -1; brief eye contact under 10 seconds is -2; movement or eye opening to voice without eye contact is -3. Count the eye contact silently in your head. Do not eyeball it. Step 3 is physical stimulation. If there is no response to voice, apply a physical stimulus such as a shoulder shake or a trapezius squeeze. Sternal rub is no longer recommended in most ICU sedation protocols due to bruising. Movement or eye opening to physical stimulation is -4. No response to either voice or physical stimulation is -5. Always document which stimulus you used. "No response to physical stimulation (trapezius squeeze)" is defensible; "no response to pain" without specifying the stimulus is not.

How Nurses Document a RASS Score

A complete RASS chart entry includes five elements: the time, the score, the stimulus that produced the score (observation, voice, or physical), the target sedation band ordered by the team, and the action taken if the score falls outside the target band. The chart entry pattern looks like this: "0800 RASS -3 to voice (no eye contact). Target band -2 to 0. Propofol gtt at 30 mcg/kg/min, decreased to 25 mcg/kg/min per orders, reassess RASS in 30 minutes." Charting only the number ("RASS -3") without the stimulus, target, or action leads to flags in chart audits and complications in legal reviews, especially if the patient self-extubates after a missed downward titration. After every continuous sedative titration, reassess within 15 to 30 minutes and document the new RASS to show whether the change had its intended effect. RASS is not a once-per-shift assessment in a sedated ICU patient; it requires repeated assessments tied to titration events and the unit's standard interval, commonly Q2h or Q4h depending on stability.

RASS, Target Sedation Bands, and the Sedation Interruption Decision

The score alone does not indicate whether to titrate; instead, compare it with the team's target sedation band. PADIS (Devlin et al, 2018) recommends light sedation, defined as RASS -2 to 0, for most mechanically ventilated patients unless a specific indication for deeper sedation exists, such as refractory intracranial pressure, severe ARDS requiring neuromuscular blockade, or status epilepticus. Deep sedation is classified as RASS -4 or -5. If the score falls below the target band, decrease the continuous sedative; if it exceeds the target band, increase it. Daily sedation interruption, known as the spontaneous awakening trial (SAT), typically pauses continuous sedatives until the patient reaches RASS -1 to 0. At that point, the team assesses for delirium using CAM-ICU, reassesses pain, and decides on a spontaneous breathing trial. Charting the SAT pattern in real time is crucial. Document the time the gtt was held, the time the RASS reached the SAT goal, the patient's RASS at the goal, and the next step (SBT, sedative resumed, provider notified). The audit trail of an SAT protects the team if the patient agitates and self-extubates during the trial.

Sedation Documentation in NurseChartingPro

NurseChartingPro captures CIWA-Ar (alcohol withdrawal) and COWS (opioid withdrawal) scores as structured fields in the Medical Monitoring category. Nurses currently use these validated tools for the score-intervene-reassess loop in withdrawal patients. Although RASS is on the roadmap, the app does not yet include a structured RASS field. When charting on a sedated ICU patient in NCP, document the RASS in the free-text Notes section using the chart-entry pattern outlined above (time, score, stimulus, target band, action). This ensures the narrative generated by the app includes a clear assessment. Once the structured RASS field is available, this documentation habit will smoothly integrate into the structured workflow, maintaining your charting routine.

Common Mistakes

Charting Only the Number Without the Stimulus

Weak: RASS -3.
Strong: RASS -3 to voice (no eye contact). Target band is -2 to 0. Propofol decreased from 30 to 25 mcg/kg/min; reassess in 30 minutes.

RASS without the stimulus provides only part of the score. The next nurse cannot determine whether the patient was unresponsive to physical stimulation or simply not yet escalated past voice. Document the highest stimulus used.

Confusing -2 (Light Sedation) With -3 (Moderate Sedation)

Weak: RASS -2, drowsy to voice.
Strong: RASS -3, opened eyes to voice for 2 seconds without eye contact.

The clinical distinction between -2 and -3 hinges on eye contact, not just duration. Brief eye contact lasting under 10 seconds indicates -2; movement or eye opening to voice without eye contact indicates -3. Scoring as "drowsy" without specifying eye contact leads to scoring errors.

Skipping Observation and Going Straight to Voice

Weak: RASS +1 (the patient responded restlessly when called).
Strong: RASS +1 (observed restlessness, anxious posture, no aggressive movement).

Scores +4 through 0 should be assigned by observation alone. Adding a voice or physical stimulus the patient did not need overestimates arousal and undertreats agitation.

Charting RASS Without the Target Band

Weak: 0900 RASS -1, no change to propofol drip.
Strong: 0900 RASS -1, within target band of -2 to 0, no change to propofol gtt.

RASS -1 may indicate light sedation, target sedation, or deep sedation based on the team's sedation goal for the patient. Without the target band in your chart entry, the next reader cannot determine whether your action or inaction was appropriate.

Performing CAM-ICU on a Patient at RASS -4 or -5

Weak: RASS -4. CAM-ICU negative.
Strong: RASS -4. CAM-ICU not assessed (patient at RASS -4, which is deeper than the CAM-ICU validity range of RASS -3 or higher).

CAM-ICU requires patient participation in attention testing, meaning RASS -3 or above. Documenting a CAM-ICU negative for a deeply sedated patient yields a meaningless result and undermines the chart. Follow the protocol: assess RASS first, then perform CAM-ICU only if the patient is arousable enough for testing.

Mr. HayesAge 67 — Postoperative day 1 after open abdominal aortic aneurysm repair, mechanically ventilated, sedated on propofol gtt
fictional patient

Scenario

As the day shift ICU nurse, you are caring for Mr. Hayes, who was admitted overnight after an open AAA repair. He is intubated on assist control with a propofol gtt at 30 mcg/kg/min and a fentanyl PCA. The night shift's last RASS at 0500 was -3. The intensivist plans to extubate this morning and asks you to titrate to a SAT goal of RASS -1 to 0 by 0900 rounds.

Chart Entry

0800 Sedation Assessment:

RASS -3 to voice. Eyes opened briefly without sustained eye contact, no movement.
Stimulus: stated "Mr. Hayes, open your eyes and look at me" twice.
Target band: -1 to 0 (SAT goal per intensivist for planned extubation).
Action: propofol gtt decreased from 30 to 20 mcg/kg/min per protocol. Fentanyl PCA continued unchanged.
Reassess RASS in 30 minutes.

0830 Sedation Reassessment:

RASS -2 to voice. Brief eye contact for approximately 4 seconds, no sustained tracking.
Stimulus: voice only.
Target band: -1 to 0.
Action: propofol gtt decreased to 10 mcg/kg/min.
Reassess RASS in 30 minutes.

0900 Sedation Reassessment:

RASS -1 to voice. Sustained eye contact for 15 seconds, follows the command "squeeze my hand" bilaterally, no agitation, no aggressive movement.
Stimulus: voice only.
Target band: -1 to 0 (within target).
CAM-ICU: negative (RASS now within validity range).
Action: propofol gtt held per SAT protocol. Intensivist notified at 0902 for SBT and extubation assessment. Patient comfortable, vent triggering well, no signs of pain on CPOT.

Annotations

Stimulus documented at every score:
Each entry names the stimulus used (voice, with the exact phrase) so the next reader can reproduce the assessment.
Target band on every entry:
The SAT goal of -1 to 0 appears in every reassessment, showing the team is titrating toward a defined endpoint.
Reassessment timing tied to titration:
Each titration is followed by a 30-minute RASS reassessment, demonstrating the expected score-titrate-reassess loop in ICU sedation.
CAM-ICU sequenced after RASS:
CAM-ICU is documented only after RASS reaches -1, which is within the validity range. A negative CAM-ICU at RASS -3 would have been uninterpretable.
SAT outcome documented:
The 0900 entry shows the SAT goal was reached, the gtt was held, and the team was notified, closing the SAT documentation loop.

Pro Tips

  • Always Score Top Down, Not Bottom Up: Read the RASS from +4 down to -5 and assign the first descriptor that matches the patient. Scoring bottom-up, such as asking "Is this -2 or -3?", increases the risk of misclassification because it skips the agitation tier entirely.
  • The 10-Second Eye Contact Rule Is Real, Count It: The clinical distinction between RASS -1 and -2 hinges on whether eye contact lasts 10 seconds or longer. Count silently in your head; don't estimate visually. The titration decision related to RASS -1 versus -2 varies across most ICU sedation protocols, and the eye contact rule serves as the deciding factor.
  • Document the Target Band on Every RASS Entry: A bare RASS score fails to inform the next reader whether your action was correct. Always pair each RASS with the target band the team set. This simple addition transforms the chart entry from a snapshot into an action-oriented note that can withstand a chart audit.
  • Reassess Within 30 Minutes of Every Continuous Sedative Titration: RASS is not a once-a-shift assessment when a continuous sedative is running. Every titration generates a new reassessment within 15 to 30 minutes, documented with the new score. This was the habit my critical-care clinical instructor drilled into us, and the chart pattern is what proves the titration was effective.
  • Pair RASS With CAM-ICU Only When RASS Is -3 or Higher: CAM-ICU requires patient participation in attention testing. A patient with a RASS of -4 or -5 cannot participate, making a CAM-ICU negative result on a deeply sedated patient meaningless and careless. Start with RASS; use CAM-ICU only if the patient is arousable enough for testing.

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