ID

22633

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

Versies (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 -
Geüploaded op

8 juni 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

Duits Engels

Glasgow Coma Scale Routine documentation in German hospitals DMI

1 Formulieren  
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

Alias
UMLS CUI [1]
C4086337
Best verbal response
Beschrijving

Verbal response

Datatype

integer

Alias
UMLS CUI [1]
C2830372
Best motor response
Beschrijving

Motor response

Datatype

integer

Alias
UMLS CUI [1]
C0559290
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

Alias
UMLS CUI [1]
C1271007
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

Alias
UMLS CUI [1]
C4086337
Best verbal response
Beschrijving

Verbal response

Datatype

integer

Alias
UMLS CUI [1]
C2830372
Best motor response
Beschrijving

Motor response

Datatype

integer

Alias
UMLS CUI [1]
C0559290
Sum
Beschrijving

Glasgow coma scale, score

Datatype

integer

Alias
UMLS CUI [1]
C1271007
Pupils
Beschrijving

Pupils

Datatype

text

Pupillary light reflex
Beschrijving

Pupillary light reflex

Datatype

text

Corneal reflex
Beschrijving

Corneal reflex

Datatype

text

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Similar models

Glasgow Coma Scale Routine documentation in German hospitals DMI

1 Formulieren
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
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
C4086337 (UMLS CUI [1])
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
C2830372 (UMLS CUI [1])
Best verbal response
Code List
Best verbal response
CL Item
Oriented, converses normally (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
C0559290 (UMLS CUI [1])
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 (decorticate response)  (3)
CL Item
Extension to painful stimuli (decerebrate response)  (2)
CL Item
Makes no movements  (1)
Glasgow coma scale, score
Item
Total points
integer
C1271007 (UMLS CUI [1])
Date
Item
Date
date
Signature physician
Item
Signature physician
text
Item Group
GCS grading sheet
Time
Item
Time
time
Item
Eye response
integer
C4086337 (UMLS CUI [1])
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
C2830372 (UMLS CUI [1])
Best verbal response
Code List
Best verbal response
CL Item
Oriented, converses normally (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
C0559290 (UMLS CUI [1])
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 (decorticate response)  (3)
CL Item
Extension to painful stimuli (decerebrate response)  (2)
CL Item
Makes no movements  (1)
Glasgow coma scale, score
Item
Sum
integer
C1271007 (UMLS CUI [1])
Pupils
Item
Pupils
text
Pupillary light reflex
Item
Pupillary light reflex
text
Corneal reflex
Item
Corneal reflex
text
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