ID

23591

Beschrijving

Derived from www.openehr.org . Use to record clinical responses of an adult subject of care to stimuli. It is commonly used to establish a baseline conscious state and neurological function assessment and/or to detect patients who may require immediate medical intervention. The Glasgow coma scale has three subscales E (eye), V (verbal) and M (motor). In clinical practice all three subscales are reported individually plus the 'Total score', if applicable. A recorded response for each of E, V and M is mandatory. If a response cannot be tested, then the 'Not Applicable' null flavour should be recorded; do not use the 'None' ordinal value to record a missing component. Details about the reason for not being able to test a response can be recorded in the 'Confounding factors' data element. The 'Total score' can be derived as the sum of the recorded eye, motor and verbal response scores. It is not appropriate to report a 'Total score' when one or more components are not testable because the score will be artificially low - in this situation record the EVM profile instead. The three response values are considered separately as well as their sum. The 'EVM profile' can be derived as a concatenation of each of the recorded eye, motor and verbal response scores. For example, E3 V4 M2 represents the conscious state of a subject who opens eyes to speech, utters incomprehensible sounds and has an extensor response to stimulation. The minimum possible 'Total score' value is 3 (equivalent to E1 V1 M1) and the maximum possible is 15 (equivalent to E4 V5 M6). In practical use, Glasgow coma scale is recorded as one component of clinical monitoring, using sequential and repeated point-in-time measurements. Date and time should be recorded for each measurement, as well as any factors that may influence interpretation of changes. Changes in 'Total score' or any E, V or M values may have as much clinical significance as the value recorded initially.

Link

www.openehr.org

Trefwoorden

  1. 09-07-17 09-07-17 - Martin Dugas
  2. 09-07-17 09-07-17 - Martin Dugas
  3. 09-07-17 09-07-17 - Martin Dugas
Geüploaded op

9 juli 2017

DOI

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Licentie

Creative Commons BY-NC 3.0

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Glasgow Coma Scale (EHR Archetype)

openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1

  1. StudyEvent: openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1
    1. openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1
openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1.xml
Beschrijving

openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1.xml

Glasgow coma scale
Beschrijving

Fifteen point scale used to assess impairment of consciousness in response to defined stimuli. More correctly known as the Modified Glasgow coma scale.

Datatype

text

Alias
UMLS CUI [1]
C0017594
Any point in time event
Beschrijving

Unspecified point in time event which may be explicitly defined in a template or at run-time.

Datatype

text

Best verbal response (V)
Beschrijving

Best verbal response to test stimulus.

Datatype

text

Alias
UMLS CUI [1]
C3648957
Best motor response (M)
Beschrijving

Best motor response to test stimulus.

Datatype

text

Alias
UMLS CUI [1]
C3648958
Best eye response (E)
Beschrijving

Best response of eyes to test stimulus.

Datatype

text

Alias
UMLS CUI [1]
C3648956
Total score
Beschrijving

The sum of the ordinal scores recorded for each of the three component responses.

Datatype

integer

Alias
UMLS CUI [1]
C1271007
EVM profile
Beschrijving

Alternative assessment to 'Total Score' where the Eye Verbal Motor profile is expressed as three discrete components.

Datatype

text

Alias
UMLS CUI [1]
C3846158
Comment
Beschrijving

Additional narrative about the measurement of the scale not captured in other fields.

Datatype

text

Alias
UMLS CUI [1]
C0947611
Extension
Beschrijving

Additional information required to capture local content or to align with other reference models/formalisms.

Datatype

text

Alias
UMLS CUI [1]
C1546922
Confounding factors
Beschrijving

Narrative record of factors that may have contributed to the GCS scores.

Datatype

text

Alias
UMLS CUI [1]
C0009673

Similar models

openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1

  1. StudyEvent: openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1
    1. openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Glasgow coma scale
Item
Glasgow coma scale
text
C0017594 (UMLS CUI [1])
Any point in time event
Item
Any point in time event
text
Item
Best verbal response (V)
text
C3648957 (UMLS CUI [1])
Code List
Best verbal response (V)
CL Item
None (1)
C2012060 (UMLS CUI-1)
CL Item
Sounds (2)
C2012057 (UMLS CUI-1)
CL Item
Words (3)
C2012058 (UMLS CUI-1)
CL Item
Confused (4)
C2012056 (UMLS CUI-1)
CL Item
Orientated (5)
C2012059 (UMLS CUI-1)
Item
Best motor response (M)
text
C3648958 (UMLS CUI [1])
Code List
Best motor response (M)
CL Item
None (1)
C2012054 (UMLS CUI-1)
CL Item
Extension (2)
C2012050 (UMLS CUI-1)
CL Item
Abnormal flexion (3)
C2012051 (UMLS CUI-1)
CL Item
Normal flexion (4)
C2012052 (UMLS CUI-1)
CL Item
Localising (5)
C2012053 (UMLS CUI-1)
CL Item
Obeys commands (6)
C2012055 (UMLS CUI-1)
Item
Best eye response (E)
text
C3648956 (UMLS CUI [1])
Code List
Best eye response (E)
CL Item
None (1)
C2012045 (UMLS CUI-1)
CL Item
To pressure (2)
C2012047 (UMLS CUI-1)
CL Item
To sound (3)
C2012048 (UMLS CUI-1)
CL Item
Spontaneous (4)
C2012046 (UMLS CUI-1)
GCS score
Item
Total score
integer
C1271007 (UMLS CUI [1])
EVM profile
Item
EVM profile
text
C3846158 (UMLS CUI [1])
Comment
Item
Comment
text
C0947611 (UMLS CUI [1])
Extension
Item
Extension
text
C1546922 (UMLS CUI [1])
Confounding factors
Item
Confounding factors
text
C0009673 (UMLS CUI [1])

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