ID

22371

Beschrijving

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/

Trefwoorden

  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 -
Geüploaded op

31 mei 2017

DOI

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Licentie

Creative Commons BY-NC 3.0

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Glasgow Coma Scale Routine documentation in German hospitals DMI

Glasgow Coma Scale Routine documentation in German hospitals DMI

Bodily state at admission
Beschrijving

Bodily state at admission

Dyspnea on exertion
Beschrijving

Dyspnea on exertion (DOE)

Datatype

boolean

NYHA classification
Beschrijving

NYHA classification

Datatype

text

Date
Beschrijving

Date

Datatype

date

Signature, physician
Beschrijving

Signature, physician

Datatype

text

Glasgow Coma Scale (GCS)
Beschrijving

Glasgow Coma Scale (GCS)

Eye response
Beschrijving

Eye response

Datatype

integer

Best verbal response
Beschrijving

Best verbal response

Datatype

integer

Best motor response
Beschrijving

Best motor response

Datatype

integer

Total points
Beschrijving

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.

Datatype

integer

Date
Beschrijving

Date

Datatype

date

Signature physician
Beschrijving

Signature physician

Datatype

text

GCS grading sheet
Beschrijving

GCS grading sheet

Time
Beschrijving

Time

Datatype

time

Eye response
Beschrijving

Eye response

Datatype

integer

Best verbal response
Beschrijving

Best verbal response

Datatype

integer

Best motor response
Beschrijving

Best motor response

Datatype

integer

Sum
Beschrijving

GCS Sum

Datatype

integer

Pupils
Beschrijving

Pupils

Datatype

text

Pupillary light reflex
Beschrijving

Pupillary light reflex

Datatype

text

Corneal reflex
Beschrijving

Corneal reflex

Datatype

text

Pediatric Glasgow Coma Scale (PGCS)
Beschrijving

Pediatric Glasgow Coma Scale (PGCS)

Name
Beschrijving

Name

Datatype

text

Date of birth
Beschrijving

Date of birth

Datatype

date

Sheet
Beschrijving

Sheet

Datatype

text

Ward
Beschrijving

Ward

Datatype

text

PGCS grading sheet
Beschrijving

PGCS grading sheet

Date
Beschrijving

Date

Datatype

date

Time
Beschrijving

Time

Datatype

time

I Verbal response
Beschrijving

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

Datatype

integer

II Motor response
Beschrijving

II Motor response

Datatype

integer

III Eye response
Beschrijving

III Eye response

Datatype

integer

IV Eye symptoms
Beschrijving

IV Eye symptoms

Datatype

integer

Total points
Beschrijving

Total points

Datatype

integer

Similar models

Glasgow Coma Scale Routine documentation in German hospitals DMI

Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Bodily state at admission
Dyspnea on exertion (DOE)
Item
Dyspnea on exertion
boolean
Item
NYHA classification
text
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
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
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
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
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
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
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
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
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
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
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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