ID

22917

Description

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/

Keywords

  1. 5/31/17 5/31/17 -
  2. 6/8/17 6/8/17 -
  3. 6/16/17 6/16/17 -
  4. 8/2/17 8/2/17 -
Uploaded on

June 16, 2017

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0

Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Glasgow Coma Scale Routine documentation in German hospitals DMI

Glasgow Coma Scale Routine documentation in German hospitals DMI

Bodily state at admission
Description

Bodily state at admission

Dyspnea on exertion
Description

Dyspnea on exertion (DOE)

Data type

boolean

NYHA classification
Description

NYHA classification

Data type

text

Date
Description

Date

Data type

date

Signature, physician
Description

Signature, physician

Data type

text

Glasgow Coma Scale (GCS)
Description

Glasgow Coma Scale (GCS)

Eye response
Description

Eye response

Data type

integer

Alias
UMLS CUI [1]
C4086337
Best verbal response
Description

Verbal response

Data type

integer

Alias
UMLS CUI [1]
C2830372
Best motor response
Description

Motor response

Data type

integer

Alias
UMLS CUI [1]
C0559290
Total points
Description

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.

Data type

integer

Alias
UMLS CUI [1]
C1271007
Date
Description

Date

Data type

date

Signature physician
Description

Signature physician

Data type

text

Similar models

Glasgow Coma Scale Routine documentation in German hospitals DMI

Name
Type
Description | Question | Decode (Coded Value)
Data type
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
C4086337 (UMLS CUI [1])
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])
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])
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

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial