ID

22917

Description

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

Lien

http://www.dmi.de/

Mots-clés

  1. 31/05/2017 31/05/2017 -
  2. 08/06/2017 08/06/2017 -
  3. 16/06/2017 16/06/2017 -
  4. 02/08/2017 02/08/2017 -
Téléchargé le

16 juin 2017

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0

Modèle Commentaires :

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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
Description

Bodily state at admission

Dyspnea on exertion
Description

Dyspnea on exertion (DOE)

Type de données

boolean

NYHA classification
Description

NYHA classification

Type de données

text

Date
Description

Date

Type de données

date

Signature, physician
Description

Signature, physician

Type de données

text

Glasgow Coma Scale (GCS)
Description

Glasgow Coma Scale (GCS)

Eye response
Description

Eye response

Type de données

integer

Alias
UMLS CUI [1]
C4086337
Best verbal response
Description

Verbal response

Type de données

integer

Alias
UMLS CUI [1]
C2830372
Best motor response
Description

Motor response

Type de données

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.

Type de données

integer

Alias
UMLS CUI [1]
C1271007
Date
Description

Date

Type de données

date

Signature physician
Description

Signature physician

Type de données

text

Similar models

Glasgow Coma Scale Routine documentation in German hospitals DMI

Name
Type
Description | Question | Decode (Coded Value)
Type de données
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

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