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Table of contents
  1. 1. Clinical Trial
  2. 2. Routine Documentation
  3. 3. Registry/Cohort Study
  4. 4. Quality Assurance
  5. 5. Data Standard
  6. 6. Patient-Reported Outcome
  7. 7. Medical Specialty
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- 7/9/17 - 1 form, 1 itemgroup, 7 items, 4 languages
Itemgroup: openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1.xml
Derived from . 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.
- 6/4/17 - 1 form, 3 itemgroups, 33 items, 2 languages
Itemgroups: Maternal Family History,Paternal Family History,Siblings Family History
- 7/9/16 - 1 form, 20 itemgroups, 313 items, 1 language
Itemgroups: Medical History,Befund,Clinical presentation,General therapy,Lab,Diagnostics,Cor,Hematology,Gastrointestinal system,Diabetes,Kidney,CNS,Lung,Psychiatrics,Epicrisis,Consultation,Clinical course,Mobilization and social service,Patient education and discharge,Procedere
- 6/20/18 - 1 form, 2 itemgroups, 14 items, 2 languages
Itemgroups: General information,Vital Sign

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