2 Assessment

2.1 In the community

Identifying severe COVID-19


Use the following signs and symptoms to help identify people with COVID‑19 with the most severe illness:

  • severe shortness of breath at rest or difficulty breathing

  • reduced oxygen saturation levels measured by pulse oximetry (see recommendation 2.1.2 on pulse oximetry levels that indicate serious illness)

  • coughing up blood

  • blue lips or face

  • feeling cold and clammy with pale or mottled skin

  • collapse or fainting (syncope)

  • new confusion

  • becoming difficult to rouse

  • reduced urine output.

    For signs and symptoms to help identify paediatric inflammatory multisystem syndrome (PIMS) temporally associated with COVID-19 (PIMS-TS), see the guidance on PIMS from the Royal College of Paediatrics and Child Health. [23 March 2021]


When pulse oximetry is available in primary and community care settings, to assess the severity of illness and detect early deterioration, use:

  • NHS England's guide to pulse oximetry in people 18 years and over with COVID-19

  • oxygen saturation levels below 91% in room air at rest in children and young people (17 years and under) with COVID-19. [23 March 2021, amended 27 May 2021]

Assessing shortness of breath (dyspnoea) is important but may be difficult via remote consultation. Tools such as the Medical Research Council's dyspnoea scale or the Centre for Evidence-Based Medicine's review of ways of assessing dyspnoea (breathlessness) by telephone or video can be useful.

The National Early Warning Score (NEWS) 2 tool may be used in adults in addition to clinical judgement to assess a person's risk of deterioration. Note that use of NEWS2 is not advised in children or pregnant women. Although the NEWS2 tool is not validated for predicting the risk of clinical deterioration in prehospital settings, it may be a helpful adjunct to clinical judgement in adults. A face-to-face consultation should not be arranged solely to calculate a NEWS2 score.

Locally approved Paediatric Early Warning Scores (PEWS) should be used for children. When using early warning scores, ensure that readings are based on calibrated machines. Be aware that readings may be incomplete when doing remote consultations.

Care planning


Discuss with people with COVID-19, and their families and carers, the benefits and risks of hospital admission or other acute care delivery services (for example, virtual wards or hospital at home teams). [23 March 2021]


Explain that people with COVID-19 may deteriorate rapidly. Discuss future care preferences at the first assessment to give people who do not have existing advance care plans an opportunity to express their preferences. [23 March 2021]

For a short explanation of why the panel made these recommendations, see the rationale section on assessment in the community.

2.2 In hospital


When a person is admitted to hospital with COVID-19, ensure a holistic assessment is done, including discussion about their treatment expectations and care goals:

  • Document and assess the stability of underlying health conditions, involving relevant specialists as needed.

  • Use the Clinical Frailty Scale (CFS) when appropriate, available from the NHS Specialised Clinical Frailty Network, to assess baseline health and inform discussions on treatment expectations.

  • Use the CFS within an individualised assessment of frailty.

  • Do not use the CFS for younger people, people with stable long-term disabilities (for example, cerebral palsy), learning disabilities or autism. Make an individualised assessment of frailty in these people, using clinical assessment and alternative scoring methods.

  • Record the assessment and discussion in the person's medical records.

    For assessment of paediatric inflammatory multisystem syndrome (PIMS), follow the guidance on PIMS from the Royal College of Paediatrics and Child Health. [23 March 2021]


When making decisions about the care of children and young people under 18 years, people with learning disabilities or adults who lack mental capacity for health decision making, for example, people with advanced dementia, see NICE's guideline on decision making and mental capacity.

Ensure discussions on significant care interventions involve families and carers as appropriate, and local experts or advocates. [23 March 2021]