ID

22371

Beschreibung

Routine documentation in German hospitals. Source file name: VL010106_Glasgow_Coma_Scale Examplary forms provided by DMI (http://www.dmi.de/)

Link

http://www.dmi.de/

Stichworte

Versionen (4)
  1. 31.05.17 31.05.17 -
  2. 08.06.17 08.06.17 -
  3. 16.06.17 16.06.17 -
  4. 02.08.17 02.08.17 -
Hochgeladen am

31. Mai 2017

DOI

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Creative Commons BY-NC 3.0
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Glasgow Coma Scale Routine documentation in German hospitals DMI

Deutsch Englisch

Glasgow Coma Scale Routine documentation in German hospitals DMI

1 Formulare  
Bodily state at admission
Beschreibung

Bodily state at admission

Dyspnea on exertion
Beschreibung

Dyspnea on exertion (DOE)

Datentyp

boolean

NYHA classification
Beschreibung

NYHA classification

Datentyp

text

Date
Beschreibung

Date

Datentyp

date

Signature, physician
Beschreibung

Signature, physician

Datentyp

text

Glasgow Coma Scale (GCS)
Beschreibung

Glasgow Coma Scale (GCS)

Eye response
Beschreibung

Eye response

Datentyp

integer

Best verbal response
Beschreibung

Best verbal response

Datentyp

integer

Best motor response
Beschreibung

Best motor response

Datentyp

integer

Total points
Beschreibung

Severe traumatic brain injury = 8 (or rapid decline of GCS by two points within short interval (15'-30')) Moderate traumatic brain injury = 9–12 Minor traumatic brain injury=13-15. The findings are written down on the respective sheet, time is also recorded. The answers or reactions of the patient are marked with a cross. The grading may be performed immediately or later.

Datentyp

integer

Date
Beschreibung

Date

Datentyp

date

Signature physician
Beschreibung

Signature physician

Datentyp

text

GCS grading sheet
Beschreibung

GCS grading sheet

Time
Beschreibung

Time

Datentyp

time

Eye response
Beschreibung

Eye response

Datentyp

integer

Best verbal response
Beschreibung

Best verbal response

Datentyp

integer

Best motor response
Beschreibung

Best motor response

Datentyp

integer

Sum
Beschreibung

GCS Sum

Datentyp

integer

Pupils
Beschreibung

Pupils

Datentyp

text

Pupillary light reflex
Beschreibung

Pupillary light reflex

Datentyp

text

Corneal reflex
Beschreibung

Corneal reflex

Datentyp

text

Pediatric Glasgow Coma Scale (PGCS)
Beschreibung

Pediatric Glasgow Coma Scale (PGCS)

Name
Beschreibung

Name

Datentyp

text

Date of birth
Beschreibung

Date of birth

Datentyp

date

Sheet
Beschreibung

Sheet

Datentyp

text

Ward
Beschreibung

Ward

Datentyp

text

PGCS grading sheet
Beschreibung

PGCS grading sheet

Date
Beschreibung

Date

Datentyp

date

Time
Beschreibung

Time

Datentyp

time

I Verbal response
Beschreibung

Choose answer in relation to age: 1-24 months / >24 months

Datentyp

integer

II Motor response
Beschreibung

II Motor response

Datentyp

integer

III Eye response
Beschreibung

III Eye response

Datentyp

integer

IV Eye symptoms
Beschreibung

IV Eye symptoms

Datentyp

integer

Total points
Beschreibung

Total points

Datentyp

integer

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Ähnliche Modelle

Glasgow Coma Scale Routine documentation in German hospitals DMI

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Bodily state at admission
Dyspnea on exertion (DOE)
Item
Dyspnea on exertion
boolean
Item
NYHA classification
text
NYHA classification
Code List
NYHA classification
CL Item
NYHA I (NYHA I)
CL Item
NYHA II (NYHA II)
CL Item
NYHA III (NYHA III)
CL Item
NYHA IV (NYHA IV)
CL Item
none (none)
Date
Item
Date
date
Signature, physician
Item
Signature, physician
text
Item Group
Glasgow Coma Scale (GCS)
Item
Eye response
integer
Opening eyes
Code List
Eye response
CL Item
opens eyes spontaneously (4)
CL Item
opens eyes in response to voice (3)
CL Item
opens eyes in response to painful stimuli (2)
CL Item
does not open eyes (1)
Item
Best verbal response
integer
Best verbal response
Code List
Best verbal response
CL Item
Oriented (5)
CL Item
Confused, disoriented (4)
CL Item
Utters incoherent words (3)
CL Item
Incomprehensible sounds (2)
CL Item
Makes no sounds (1)
Item
Best motor response
integer
Best motor response
Code List
Best motor response
CL Item
Obeys commands (6)
CL Item
Localizes painful stimuli (5)
CL Item
Flexion / Withdrawal to painful stimuli (4)
CL Item
Abnormal flexion to painful stimuli (3)
CL Item
Extension to painful stimuli (2)
CL Item
Makes no movements (1)
Total points
Item
Total points
integer
Date
Item
Date
date
Signature physician
Item
Signature physician
text
Item Group
GCS grading sheet
Time
Item
Time
time
Item
Eye response
integer
Eye response
Code List
Eye response
CL Item
opens eyes spontaneously (4)
CL Item
opens eyes in response to voice (3)
CL Item
opens eyes in response to painful stimuli (2)
CL Item
does not open eyes (1)
Item
Best verbal response
integer
Best verbal response
Code List
Best verbal response
CL Item
Oriented (5)
CL Item
Confused, disoriented (4)
CL Item
Utters incoherent words (3)
CL Item
Incomprehensible sounds (2)
CL Item
Makes no sounds (1)
Item
Best motor response
integer
Best motor response
Code List
Best motor response
CL Item
Obeys commands (6)
CL Item
Localizes painful stimuli (5)
CL Item
Flexion / Withdrawal to painful stimuli (4)
CL Item
Abnormal flexion to painful stimuli (3)
CL Item
Extension to painful stimuli (2)
CL Item
Makes no movements (1)
GCS Sum
Item
Sum
integer
Pupils
Item
Pupils
text
Pupillary light reflex
Item
Pupillary light reflex
text
Corneal reflex
Item
Corneal reflex
text
Item Group
Pediatric Glasgow Coma Scale (PGCS)
Name
Item
Name
text
Date of birth
Item
Date of birth
date
Sheet
Item
Sheet
text
Ward
Item
Ward
text
Item Group
PGCS grading sheet
Date
Item
Date
date
Time
Item
Time
time
Item
I Verbal response
integer
I Verbal response
Code List
I Verbal response
CL Item
Smiles, oriented to sounds, follows objects, interacts / Oriented, appropriate (5)
CL Item
Cries but consolable, inappropriate interactions / Confused (4)
CL Item
Inconsistently inconsolable, moaning / Inappropriate words (3)
CL Item
Inconsolable, agitated / Incomprehensible sounds (2)
CL Item
No response (1)
Item
II Motor response
integer
II Motor response
Code List
II Motor response
CL Item
Infant moves spontaneously or purposefully (6)
CL Item
Infant withdraws from touch (5)
CL Item
Infant withdraws from pain (4)
CL Item
Abnormal flexion to pain for an infant (decorticate response) (3)
CL Item
Extension to pain (decerebrate response) (2)
CL Item
No motor response (1)
Item
III Eye response
integer
III Eye response
Code List
III Eye response
CL Item
Eyes opening spontaneously (4)
CL Item
Eye opening to speech (3)
CL Item
Eye opening to pain (2)
CL Item
No eye opening or response (1)
Item
IV Eye symptoms
integer
IV Eye symptoms
Code List
IV Eye symptoms
CL Item
Conjugate eye movement, pupillary light reflex (4)
CL Item
Doll's eye phenomenon with conjugate bulb movements (3)
CL Item
Divergent eye balls, especially when triggering doll's eye phenomenon or during ear canal douche; no eye movements (2)
CL Item
no spontaneous eye movements, pupils unresponsive to light (1)
Total points
Item
Total points
integer
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