ID

22633

Beskrivning

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

Länk

http://www.dmi.de/

Nyckelord

Versioner (4)
  1. 2017-05-31 2017-05-31 -
  2. 2017-06-08 2017-06-08 -
  3. 2017-06-16 2017-06-16 -
  4. 2017-08-02 2017-08-02 -
Uppladdad den

8 juni 2017

DOI

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Licens

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

Tysk Engelsk

Glasgow Coma Scale Routine documentation in German hospitals DMI

1 Formulär  
Bodily state at admission
Beskrivning

Bodily state at admission

Dyspnea on exertion
Beskrivning

Dyspnea on exertion (DOE)

Datatyp

boolean

NYHA classification
Beskrivning

NYHA classification

Datatyp

text

Date
Beskrivning

Date

Datatyp

date

Signature, physician
Beskrivning

Signature, physician

Datatyp

text

Glasgow Coma Scale (GCS)
Beskrivning

Glasgow Coma Scale (GCS)

Eye response
Beskrivning

Eye response

Datatyp

integer

Alias
UMLS CUI [1]
C4086337
Best verbal response
Beskrivning

Verbal response

Datatyp

integer

Alias
UMLS CUI [1]
C2830372
Best motor response
Beskrivning

Motor response

Datatyp

integer

Alias
UMLS CUI [1]
C0559290
Total points
Beskrivning

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.

Datatyp

integer

Alias
UMLS CUI [1]
C1271007
Date
Beskrivning

Date

Datatyp

date

Signature physician
Beskrivning

Signature physician

Datatyp

text

GCS grading sheet
Beskrivning

GCS grading sheet

Time
Beskrivning

Time

Datatyp

time

Eye response
Beskrivning

Eye response

Datatyp

integer

Alias
UMLS CUI [1]
C4086337
Best verbal response
Beskrivning

Verbal response

Datatyp

integer

Alias
UMLS CUI [1]
C2830372
Best motor response
Beskrivning

Motor response

Datatyp

integer

Alias
UMLS CUI [1]
C0559290
Sum
Beskrivning

Glasgow coma scale, score

Datatyp

integer

Alias
UMLS CUI [1]
C1271007
Pupils
Beskrivning

Pupils

Datatyp

text

Pupillary light reflex
Beskrivning

Pupillary light reflex

Datatyp

text

Corneal reflex
Beskrivning

Corneal reflex

Datatyp

text

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Similar models

Glasgow Coma Scale Routine documentation in German hospitals DMI

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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