ID

24489

Descripción

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/

Palabras clave

Versiones (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 -
Subido en

2 augustus 2017

DOI

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Licencia

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

Alemán Inglés

Glasgow Coma Scale Routine documentation in German hospitals DMI

1 formularios  
Bodily state at admission
Descripción

Bodily state at admission

Alias
UMLS CUI-1
C4019131
Dyspnea on exertion
Descripción

Dyspnea on exertion (DOE)

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0231807
NYHA classification
Descripción

NYHA classification

Tipo de datos

text

Alias
UMLS CUI [1]
C1275491
Date
Descripción

Date

Tipo de datos

date

Alias
UMLS CUI [1]
C0011008
Signature, physician
Descripción

Signature physician

Tipo de datos

text

Alias
UMLS CUI [1]
C0807938
Glasgow Coma Scale (GCS)
Descripción

Glasgow Coma Scale (GCS)

Alias
UMLS CUI-1
C0017594
Eye response
Descripción

Eye response

Tipo de datos

integer

Alias
UMLS CUI [1]
C4086337
Best verbal response
Descripción

Verbal response

Tipo de datos

integer

Alias
UMLS CUI [1]
C2830372
Best motor response
Descripción

Motor response

Tipo de datos

integer

Alias
UMLS CUI [1]
C0559290
Total points
Descripción

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.

Tipo de datos

integer

Alias
UMLS CUI [1]
C1271007
Date
Descripción

Date

Tipo de datos

date

Alias
UMLS CUI [1]
C0011008
Signature physician
Descripción

Signature physician

Tipo de datos

text

Alias
UMLS CUI [1]
C0807938
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Similar models

Glasgow Coma Scale Routine documentation in German hospitals DMI

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Bodily state at admission
C4019131 (UMLS CUI-1)
Dyspnea on exertion (DOE)
Item
Dyspnea on exertion
boolean
C0231807 (UMLS CUI [1])
Item
NYHA classification
text
C1275491 (UMLS CUI [1])
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
C0011008 (UMLS CUI [1])
Signature physician
Item
Signature, physician
text
C0807938 (UMLS CUI [1])
Item Group
Glasgow Coma Scale (GCS)
C0017594 (UMLS CUI-1)
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
C0011008 (UMLS CUI [1])
Signature physician
Item
Signature physician
text
C0807938 (UMLS CUI [1])
Volver a la parte superior de la página 

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