GlasgowComaScale-v1.2.1(2015EN): verschil tussen versies

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(Nieuwe pagina aangemaakt met '==General information== Name: '''nl.nfu.GlasgowComaScale''' link=GlasgowComaScale-v1.2.1(2015NL)<BR> Version: '''1.2.1''' <br> HCIM Status:Fin...')
 
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Regel 3: Regel 3:
Version: '''1.2.1''' <br>
Version: '''1.2.1''' <br>
HCIM Status:Final<br>
HCIM Status:Final<br>
Publication: '''2015''' <br>
Release: '''2015''' <br>
Release status: Published<br>
Release status: Published<br>
Publication date: 1-4-2015
Release date: 1-4-2015
-----
-----
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release_2015(EN)]] [[HCIM_Release_2015(EN) |Back to HCIM list ]]</div>
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release_2015(EN)]] [[HCIM_Release_2015(EN) |Back to HCIM list ]]</div>
Regel 164: Regel 164:
==Information Model==
==Information Model==
<BR>
<BR>
[[Bestand: GlasgowComaScale-v1.2.1Model(EN).png | center]]
<imagemap> Bestand:GlasgowComaScale-v1.2.1Model(EN).png | center  
rect 677 611 829 652 [[#GCS_VerbalCodelist]]
rect 677 555 839 596 [[#GCS_VerbalCodelist]]
rect 253 200 359 302 [[#9347]]
rect 233 483 385 553 [[#9345]]
rect 49 360 201 430 [[#9346]]
rect 522 617 638 687 [[#9353]]
rect 522 114 638 184 [[#9349]]
rect 677 497 805 538 [[#GCS_VerbalCodelist]]
rect 522 395 638 465 [[#9351]]
rect 522 539 638 609 [[#9352]]
rect 700 333 828 374 [[#GCS_MotorCodelist]]
rect 700 46 828 87 [[#GCS_EyesCodelist]]
rect 522 316 638 386 [[#9350]]
rect 522 35 638 105 [[#9348]]
rect 252 354 360 434 [[#9344]]
desc none
</imagemap>
<BR>
<BR>
{| border= "1"  width="1500px" style = "font-size: 9.5pt;  border: solid 1px silver; border-collapse:collapse;" cellpadding = "3px" cellspacing ="0px"  
{| border= "1"  width="1500px" style = "font-size: 9.5pt;  border: solid 1px silver; border-collapse:collapse;" cellpadding = "3px" cellspacing ="0px"  
Regel 170: Regel 187:
|style="width:30px;"|Type||style="width:100px;"|Id||colspan="6 " style="width:140px;"|Concept||Card.||style="width: 600px;"|Definition||style="width:200px;"|DefinitionCode||style="width:200px;"|Reference
|style="width:30px;"|Type||style="width:100px;"|Id||colspan="6 " style="width:140px;"|Concept||Card.||style="width: 600px;"|Definition||style="width:200px;"|DefinitionCode||style="width:200px;"|Reference
|-style="vertical-align:top; background-color: #E3E3E3; "
|-style="vertical-align:top; background-color: #E3E3E3; "
|style = "text-align:center" |[[Bestand: block.png| 20px]]
|style = "text-align:center" |[[Bestand: block.png| 20px | link=]]
||NL-CM:12.8.1
||NL-CM:12.8.1
|colspan ="6" style ="padding-left: 0px"|<span Title="NL: GlasgowComaScale">[[Bestand: arrowdown.png | 10px]]GlasgowComaScale</span>
|colspan ="6" style ="padding-left: 0px"|<span Id=9344 Title="NL: GlasgowComaScale">[[Bestand: arrowdown.png | 10px | link=]]GlasgowComaScale</span>
|
|
|Root concept of the GlasgowComaScale building block. This root concept contains all data elements of the GlasgowComaScale building block.
|Root concept of the GlasgowComaScale building block. This root concept contains all data elements of the GlasgowComaScale building block.
Regel 182: Regel 199:
|
|
|-style="vertical-align:top; background-color: transparent; "
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: TS.png| 16px]]
|style = "text-align:center" |[[Bestand: TS.png| 16px | link=]]
||NL-CM:12.8.8
||NL-CM:12.8.8
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: GlasgowComaScaleDatumTijd">[[Bestand: arrowright.png | 10px]]GlasgowComaScaleDateTime</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=9345 Title="NL: GlasgowComaScaleDatumTijd">[[Bestand: arrowright.png | 10px | link=]]GlasgowComaScaleDateTime</span>
|1
|1
|Time at which the EMV score was determined.
|Time at which the EMV score was determined.
Regel 191: Regel 208:
|
|
|-style="vertical-align:top; background-color: transparent; "
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: CO.png| 16px]]
|style = "text-align:center" |[[Bestand: CO.png| 16px | link=]]
||NL-CM:12.8.2
||NL-CM:12.8.2
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: GCS_Eyes">[[Bestand: arrowright.png | 10px]]GCS_Eyes</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=9348 Title="NL: GCS_Eyes">[[Bestand: arrowright.png | 10px | link=]]GCS_Eyes</span>
|0..1
|0..1
|Best eye response to a stimulus. The element is mandatory, but does not require a numerical value. If no value is given, the reason for this is to be provided in the ExplanationEScore concept.
|Best eye response to a stimulus. The element is mandatory, but does not require a numerical value. If no value is given, the reason for this is to be provided in the ExplanationEScore concept.
Regel 205: Regel 222:
{|
{|
|-
|-
|[[Bestand: List2.png]]||[[#GCS_EyesCodelist|GCS_EyesCodelist]]
|[[Bestand: List2.png | link=#GCS_EyesCodelist]]||[[#GCS_EyesCodelist|GCS_EyesCodelist]]
|}
|}
|-style="vertical-align:top; background-color: transparent; "
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: ST.png| 16px]]
|style = "text-align:center" |[[Bestand: ST.png| 16px | link=]]
||NL-CM:12.8.3
||NL-CM:12.8.3
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: ToelichtingEscore">[[Bestand: arrowright.png | 10px]]ExplanationEScore</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=9349 Title="NL: ToelichtingEscore">[[Bestand: arrowright.png | 10px | link=]]ExplanationEScore</span>
|0..1
|0..1
|Reason why no eye response test could be done. This is to be entered as free text. An often-used notation is the abbreviation c (closed), in the event that the eyes are closed.
|Reason why no eye response test could be done. This is to be entered as free text. An often-used notation is the abbreviation c (closed), in the event that the eyes are closed.
Regel 217: Regel 234:
|
|
|-style="vertical-align:top; background-color: transparent; "
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: CO.png| 16px]]
|style = "text-align:center" |[[Bestand: CO.png| 16px | link=]]
||NL-CM:12.8.4
||NL-CM:12.8.4
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: GCS_Motor">[[Bestand: arrowright.png | 10px]]GCS_Motor</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=9350 Title="NL: GCS_Motor">[[Bestand: arrowright.png | 10px | link=]]GCS_Motor</span>
|0..1
|0..1
|Best motor response to a stimulus. The element is mandatory, but does not require a numerical value. If no value is given, the reason for this is to be provided in the ExplanationMScore concept.
|Best motor response to a stimulus. The element is mandatory, but does not require a numerical value. If no value is given, the reason for this is to be provided in the ExplanationMScore concept.
Regel 231: Regel 248:
{|
{|
|-
|-
|[[Bestand: List2.png]]||[[#GCS_MotorCodelist|GCS_MotorCodelist]]
|[[Bestand: List2.png | link=#GCS_MotorCodelist]]||[[#GCS_MotorCodelist|GCS_MotorCodelist]]
|}
|}
|-style="vertical-align:top; background-color: transparent; "
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: ST.png| 16px]]
|style = "text-align:center" |[[Bestand: ST.png| 16px | link=]]
||NL-CM:12.8.5
||NL-CM:12.8.5
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: ToelichtingMscore">[[Bestand: arrowright.png | 10px]]ExplanationMScore</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=9351 Title="NL: ToelichtingMscore">[[Bestand: arrowright.png | 10px | link=]]ExplanationMScore</span>
|0..1
|0..1
|Reason why no motor response test could be done. This is to be entered as free text.
|Reason why no motor response test could be done. This is to be entered as free text.
Regel 243: Regel 260:
|
|
|-style="vertical-align:top; background-color: transparent; "
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: CO.png| 16px]]
|style = "text-align:center" |[[Bestand: CO.png| 16px | link=]]
||NL-CM:12.8.6
||NL-CM:12.8.6
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: GCS_Verbal">[[Bestand: arrowright.png | 10px]]GCS_Verbal</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=9352 Title="NL: GCS_Verbal">[[Bestand: arrowright.png | 10px | link=]]GCS_Verbal</span>
|0..1
|0..1
|Best verbal response to a stimulus. The element is mandatory, but does not require a numerical value. If no value is given, the reason for this is to be provided in the ExplanationVScore concept.
|Best verbal response to a stimulus. The element is mandatory, but does not require a numerical value. If no value is given, the reason for this is to be provided in the ExplanationVScore concept.
Regel 257: Regel 274:
{|
{|
|-
|-
|[[Bestand: List2.png]]||[[#GCS_VerbalCodelist|GCS_VerbalCodelist]]
|[[Bestand: List2.png | link=#GCS_VerbalCodelist]]||[[#GCS_VerbalCodelist|GCS_VerbalCodelist]]
|-
|-
|[[Bestand: List2.png]]||[[#GCS_VerbalCodelist|GCS_VerbalCodelist]]
|[[Bestand: List2.png | link=#GCS_VerbalCodelist]]||[[#GCS_VerbalCodelist|GCS_VerbalCodelist]]
|-
|-
|[[Bestand: List2.png]]||[[#GCS_VerbalCodelist|GCS_VerbalCodelist]]
|[[Bestand: List2.png | link=#GCS_VerbalCodelist]]||[[#GCS_VerbalCodelist|GCS_VerbalCodelist]]
|}
|}
|-style="vertical-align:top; background-color: transparent; "
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: ST.png| 16px]]
|style = "text-align:center" |[[Bestand: ST.png| 16px | link=]]
||NL-CM:12.8.7
||NL-CM:12.8.7
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: ToelichtingVscore">[[Bestand: arrowright.png | 10px]]ExplanationVScore</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=9353 Title="NL: ToelichtingVscore">[[Bestand: arrowright.png | 10px | link=]]ExplanationVScore</span>
|0..1
|0..1
|Reason why no verbal response test could be done. This is to be entered as free text.  
|Reason why no verbal response test could be done. This is to be entered as free text.  
Regel 274: Regel 291:
|
|
|-style="vertical-align:top; background-color: transparent; "
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: INT.png| 16px]]
|style = "text-align:center" |[[Bestand: INT.png| 16px | link=]]
||NL-CM:12.8.10
||NL-CM:12.8.10
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: TotaalScore">[[Bestand: arrowright.png | 10px]]TotalScore</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=9347 Title="NL: TotaalScore">[[Bestand: arrowright.png | 10px | link=]]TotalScore</span>
|0..1
|0..1
|The sum of the EMV scores, expressed as a number on a scale from 3-15. The value does not have to be recorded, as it can always be calculated based on the individual scores, and as recording the total is not common for a difficult to determine individual score.
|The sum of the EMV scores, expressed as a number on a scale from 3-15. The value does not have to be recorded, as it can always be calculated based on the individual scores, and as recording the total is not common for a difficult to determine individual score.
Regel 283: Regel 300:
|
|
|-style="vertical-align:top; background-color: transparent; "
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: ST.png| 16px]]
|style = "text-align:center" |[[Bestand: ST.png| 16px | link=]]
||NL-CM:12.8.9
||NL-CM:12.8.9
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: Toelichting">[[Bestand: arrowright.png | 10px]]Explanation</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=9346 Title="NL: Toelichting">[[Bestand: arrowright.png | 10px | link=]]Explanation</span>
|0..1
|0..1
|Comment on (the context of) the EMV score measurement, such as any problems or factors that may influence interpretation.
|Comment on (the context of) the EMV score measurement, such as any problems or factors that may influence interpretation.
Regel 300: Regel 317:
{|class="wikitable" width="780px" style= "font-size: 9.5pt;"
{|class="wikitable" width="780px" style= "font-size: 9.5pt;"
|-style=vertical-align:top;
|-style=vertical-align:top;
| style="background-color: #1F497D; width: 19%; color: #FFFFFF; font-weight: bold; "|GlasgowComa ScaleDatumTijd
| style="background-color: #1F497D; width: 19%; "|<font color=#FFFFFF><b>GlasgowComa</b></font><font color=#FFFFFF><b> </b></font><font color=#FFFFFF><b>Scale</b></font><font color=#FFFFFF><b>Datum</b></font><font color=#FFFFFF><b>Tijd</b></font>
| style="background-color: #1F497D; width: 7%; color: #FFFFFF; font-weight: bold; "|GCS_Eyes
| style="background-color: #1F497D; width: 7%; "|<font color=#FFFFFF><b>GCS_Eyes</b></font>
| style="background-color: #1F497D; width: 9%; color: #FFFFFF; font-weight: bold; "|GCS_Motor
| style="background-color: #1F497D; width: 9%; "|<font color=#FFFFFF><b>GCS_Motor</b></font>
| style="background-color: #1F497D; width: 9%; color: #FFFFFF; font-weight: bold; "|GCS_ Verbal
| style="background-color: #1F497D; width: 9%; "|<font color=#FFFFFF><b>GCS_</b></font><font color=#FFFFFF><b> </b></font><font color=#FFFFFF><b>Verbal</b></font>
| style="background-color: #1F497D; width: 15%; color: #FFFFFF; font-weight: bold; "|TotaalScore
| style="background-color: #1F497D; width: 15%; "|<font color=#FFFFFF><b>Tot</b></font><font color=#FFFFFF><b>aa</b></font><font color=#FFFFFF><b>l</b></font><font color=#FFFFFF><b>Score</b></font>
| style="background-color: #1F497D; width: 42%; color: #FFFFFF; font-weight: bold; "|Toelichting
| style="background-color: #1F497D; width: 42%; "|<font color=#FFFFFF><b>Toelichting</b></font>
|-style=vertical-align:top;
|-style=vertical-align:top;
| style="width: 19%; "|08-02-2013 6:43
| style="width: 19%; "|08-02-2013 6:43
Regel 321: Regel 338:
| style="width: 42%; "|
| style="width: 42%; "|
|-style=vertical-align:top;
|-style=vertical-align:top;
| style="background-color: #1F497D; width: 19%; color: #FFFFFF; font-weight: bold; "|GlasgowComa ScaleDatumTijd
| style="background-color: #1F497D; width: 19%; "|<font color=#FFFFFF><b>GlasgowComa</b></font><font color=#FFFFFF><b> </b></font><font color=#FFFFFF><b>Scale</b></font><font color=#FFFFFF><b>Datum</b></font><font color=#FFFFFF><b>Tijd</b></font>
| style="background-color: #1F497D; width: 7%; color: #FFFFFF; font-weight: bold; "|GCS_Eyes
| style="background-color: #1F497D; width: 7%; "|<font color=#FFFFFF><b>GCS_Eyes</b></font>
| style="background-color: #1F497D; width: 9%; color: #FFFFFF; font-weight: bold; "|GCS_Motor
| style="background-color: #1F497D; width: 9%; "|<font color=#FFFFFF><b>GCS_Motor</b></font>
| style="background-color: #1F497D; width: 9%; color: #FFFFFF; font-weight: bold; "|GCS_ Verbal
| style="background-color: #1F497D; width: 9%; "|<font color=#FFFFFF><b>GCS_</b></font><font color=#FFFFFF><b> </b></font><font color=#FFFFFF><b>Verbal</b></font>
| style="background-color: #1F497D; width: 15%; color: #FFFFFF; font-weight: bold; "|TotaalScore
| style="background-color: #1F497D; width: 15%; "|<font color=#FFFFFF><b>Tot</b></font><font color=#FFFFFF><b>aa</b></font><font color=#FFFFFF><b>l</b></font><font color=#FFFFFF><b>Score</b></font>
| style="background-color: #1F497D; width: 42%; color: #FFFFFF; font-weight: bold; "|Toelichting
| style="background-color: #1F497D; width: 42%; "|<font color=#FFFFFF><b>Toelichting</b></font>
|-style=vertical-align:top;
|-style=vertical-align:top;
| style="width: 19%; "|07-02-2013 11:34
| style="width: 19%; "|07-02-2013 11:34
Regel 342: Regel 359:
| style="width: 42%; "|
| style="width: 42%; "|
|-style=vertical-align:top;
|-style=vertical-align:top;
| style="background-color: #1F497D; width: 19%; color: #FFFFFF; font-weight: bold; "|GlasgowComa ScaleDatumTijd
| style="background-color: #1F497D; width: 19%; "|<font color=#FFFFFF><b>GlasgowComa</b></font><font color=#FFFFFF><b> </b></font><font color=#FFFFFF><b>Scale</b></font><font color=#FFFFFF><b>Datum</b></font><font color=#FFFFFF><b>Tijd</b></font>
| style="background-color: #1F497D; width: 7%; color: #FFFFFF; font-weight: bold; "|GCS_Eyes
| style="background-color: #1F497D; width: 7%; "|<font color=#FFFFFF><b>GCS_Eyes</b></font>
| style="background-color: #1F497D; width: 9%; color: #FFFFFF; font-weight: bold; "|GCS_Motor
| style="background-color: #1F497D; width: 9%; "|<font color=#FFFFFF><b>GCS_Motor</b></font>
| style="background-color: #1F497D; width: 9%; color: #FFFFFF; font-weight: bold; "|GCS_ Verbal
| style="background-color: #1F497D; width: 9%; "|<font color=#FFFFFF><b>GCS_</b></font><font color=#FFFFFF><b> </b></font><font color=#FFFFFF><b>Verbal</b></font>
| style="background-color: #1F497D; width: 15%; color: #FFFFFF; font-weight: bold; "|TotaalScore
| style="background-color: #1F497D; width: 15%; "|<font color=#FFFFFF><b>Tot</b></font><font color=#FFFFFF><b>aa</b></font><font color=#FFFFFF><b>l</b></font><font color=#FFFFFF><b>Score</b></font>
| style="background-color: #1F497D; width: 42%; color: #FFFFFF; font-weight: bold; "|Toelichting
| style="background-color: #1F497D; width: 42%; "|<font color=#FFFFFF><b>Toelichting</b></font>
|-style=vertical-align:top;
|-style=vertical-align:top;
| style="width: 19%; "|07-02-2013 8:00
| style="width: 19%; "|07-02-2013 8:00
Regel 609: Regel 626:




==This information model in other releases==
<ul>
<li>[[GlasgowComaScale-v3.0(2016EN) | Release 2016, (Version 3.0)]]</li>
<li>[[GlasgowComaScale-v3.1(2017EN) | Release 2017, (Version 3.1)]]</li>
</ul>
==More on this information model==
==More on this information model==
More technical information and HL7/XML documentation you can find on the Nictiz Art-Decor page about this information model[http://decor.nictiz.nl/art-decor/decor-datasets--zib1bbr-?id=2.16.840.1.113883.2.4.3.11.60.40.3.12.8] <BR>
To exchange information based on health and care information models, additional, more technical specifications are required.<BR>
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:
<ul>
<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2015bbr-?id=2.16.840.1.113883.2.4.3.11.60.5.4.2.12.8&effectiveDate=2015-04-01T00:00:00&language=en-US&scenariotree=false [[File:artdecor.jpg|16px|link=]]]</li>
<li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR [https://simplifier.net/NictizSTU3/~resources?text=zib&category=StructureDefinition [[File:fhir.png|link=]]]</li>
</ul>
This information model is also available as [[Media:nl.nfu.GlasgowComaScale-v1.2.1(2015EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.nfu.GlasgowComaScale-v1.2.1(2015EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]
This information model is also available as [[Media:nl.nfu.GlasgowComaScale-v1.2.1(2015EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.nfu.GlasgowComaScale-v1.2.1(2015EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]
==About this information==
==About this information==
The information in this wikipage is based on ''Registratie aan de bron'' publication 2015 including errata dd. 16-07-2015 <BR>
The information in this wikipage is based on ''Registratie aan de bron'' publication 2015 including errata dd. 16-07-2015 <BR>
Conditions for use are located on the mainpage [[Bestand:list2.png|link=HCIM_Mainpage]]<BR>
Conditions for use are located on the mainpage [[Bestand:list2.png|link=HCIM_Mainpage]]<BR>
This page is generated on 27/09/2017 23:59:14 <BR>
This page is generated on 24/01/2018 17:12:20 <BR>
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Versie van 25 jan 2018 00:20

General information

Name: nl.nfu.GlasgowComaScale NL.png
Version: 1.2.1
HCIM Status:Final
Release: 2015
Release status: Published
Release date: 1-4-2015

Back 16.png Back to HCIM list

Metadata

DCM::CoderList Kerngroep Registratie aan de Bron
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::CreationDate 29-11-2012
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name NFU
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.12.8
DCM::KeywordList Glascow coma schaal
DCM::LifecycleStatus Final
DCM::ModelerList Kerngroep Registratie aan de Bron
DCM::Name nl.nfu.GlasgowComaScale
DCM::PublicationDate 1-4-2015
DCM::PublicationStatus Published
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 16-7-2015
DCM::Superseeds
DCM::Version 1.2.1
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (15-02-2013) -

Publicatieversie 1.1 (01-07-2013) -

Publicatieversie 1.2 (01-04-2015)

ZIB-227 DCM::Name van klinische bouwsteen OverdrachtGlasgowComaScale aangepast van nl.nfu.OverdrachtScoreBewustzijn naar nl.nfu.OverdrachtGlasgowComaScale.
ZIB-228 De naam van de waardenlijst GCS_VerbalCodelijstBaby van concept GCS_Verbal kwam niet overeen met de tagged value.
ZIB-229 De naam van de waardenlijst GCS_VerbalCodelijstKleuter van concept GCS_Verbal kwam niet overeen met de tagged value.
ZIB-230 De naam van de waardenlijst GCS_VerbalCodelijst van concept GCS_Verbal kwam niet overeen met de tagged value.
ZIB-231 De naam van de waardenlijst GCS_EyesCodelijst van concept GCS_Eyes kwam niet overeen met de tagged value.
ZIB-232 De naam van de waardenlijst GCS_MotorCodelijst van concept GCS_Motor kwam niet overeen met de tagged value.
ZIB-308 Prefix Overdracht weggehaald bij de generieke bouwstenen
ZIB-311 waardebereik TotaalScore
ZIB-361 Naamgeving concept Opmerking aangepast

Incl. algemene wijzigingsverzoeken:

ZIB-94 Aanpassen tekst van Disclaimer, Terms of Use & Copyrights
ZIB-154 Consequenties opsplitsing Medicatie bouwstenen voor overige bouwstenen.
ZIB-200 Naamgeving SNOMED CT in tagged values klinische bouwstenen gelijk getrokken.
ZIB-201 Naamgeving OID: in tagged value notes van klinische bouwstenen gelijk getrokken.
ZIB-309 EOI aangepast
ZIB-324 Codelijsten Name en Description beginnen met een Hoofdletter
ZIB-326 Tekstuele aanpassingen conform de kwaliteitsreview kerngroep 2015

Publicatieversie 1.2.1 (16-07-2015)

ZIB-414 Richting relatie tussen constraints en waardelijsten is fout

Concept

Fifteen-point scale for expressing a person’s level of consciousness, from fully awake to deep unconsciousness, in a number: the so-called EMV score.
The Glasgow Coma Scale score or EMV (Eye-Motor-Verbal) score is a scale to measure the extent of consciousness, based on eye, verbal and motor responses to specific prescribed sound and pain stimuli.

Purpose

The GCS score provides the opportunity to document a clinical observation of a patient’s conscious state with a validated instrument which makes use of a patient’s responses to stimuli.

Evidence Base

The Glasgow Coma Scale is used to evaluate a patient’s consciousness by means of three elements:

  1. opening eyes (eye response);
  2. answering questions (verbal response);
  3. motor response.


The three response values are looked at individually and as a whole. The total is referred to as the EMV score. The minimum total score is 3 and the maximum is 15. A slightly altered scale is used for infants (age 0-2) and toddlers (age 2-5).

The EMV score can be expressed as a combination of each of the three individual scores, such as: E3M2V4 (opens eyes when spoken to, arms stretch in response to pain and patient produces incomprehensible sounds).
If one of the EMV elements cannot be evaluated - such as might be the case if a patient is intubated and incapable of verbally responding, or is paralyzed/weak and incapable of fulfilling the motor request, then the individual score is included (score 1), but with an extra comment.
V1T is used for an intubated patient, in which t = 'tube'.
Clinical decisions must be based on each of the specific data of the eyes, motor and verbal responses and, if evaluation is not possible, an explicit explanation.

Standard values for the total score, depending on age:
0-6 months : 9 and up
6-12 months : 11 and up
1-2 : 12 and up
2-5 : 13 and up
> 5 : 14 and up

Information Model


#GCS VerbalCodelist#GCS VerbalCodelist#9347#9345#9346#9353#9349#GCS VerbalCodelist#9351#9352#GCS MotorCodelist#GCS EyesCodelist#9350#9348#9344GlasgowComaScale-v1.2.1Model(EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:12.8.1 Arrowdown.pngGlasgowComaScale Root concept of the GlasgowComaScale building block. This root concept contains all data elements of the GlasgowComaScale building block.
386554004 Glasgow coma scale (assessment scale)
TS.png NL-CM:12.8.8 Arrowright.pngGlasgowComaScaleDateTime 1 Time at which the EMV score was determined.
CO.png NL-CM:12.8.2 Arrowright.pngGCS_Eyes 0..1 Best eye response to a stimulus. The element is mandatory, but does not require a numerical value. If no value is given, the reason for this is to be provided in the ExplanationEScore concept.
281395000 Glasgow coma score eye opening subscore (observable entity)
List2.png GCS_EyesCodelist
ST.png NL-CM:12.8.3 Arrowright.pngExplanationEScore 0..1 Reason why no eye response test could be done. This is to be entered as free text. An often-used notation is the abbreviation c (closed), in the event that the eyes are closed.
CO.png NL-CM:12.8.4 Arrowright.pngGCS_Motor 0..1 Best motor response to a stimulus. The element is mandatory, but does not require a numerical value. If no value is given, the reason for this is to be provided in the ExplanationMScore concept.
281396004 Glasgow Coma Score motor response subscore
List2.png GCS_MotorCodelist
ST.png NL-CM:12.8.5 Arrowright.pngExplanationMScore 0..1 Reason why no motor response test could be done. This is to be entered as free text.
CO.png NL-CM:12.8.6 Arrowright.pngGCS_Verbal 0..1 Best verbal response to a stimulus. The element is mandatory, but does not require a numerical value. If no value is given, the reason for this is to be provided in the ExplanationVScore concept.
281397008 Glasgow coma score verbal response subscore (observable entity)
List2.png GCS_VerbalCodelist
List2.png GCS_VerbalCodelist
List2.png GCS_VerbalCodelist
ST.png NL-CM:12.8.7 Arrowright.pngExplanationVScore 0..1 Reason why no verbal response test could be done. This is to be entered as free text.

An often-used notation is the addition 'Tube' for an intubated patient.

INT.png NL-CM:12.8.10 Arrowright.pngTotalScore 0..1 The sum of the EMV scores, expressed as a number on a scale from 3-15. The value does not have to be recorded, as it can always be calculated based on the individual scores, and as recording the total is not common for a difficult to determine individual score.
ST.png NL-CM:12.8.9 Arrowright.pngExplanation 0..1 Comment on (the context of) the EMV score measurement, such as any problems or factors that may influence interpretation.

Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page List2.png

Example Instances

Only available in Dutch

GlasgowComa ScaleDatumTijd GCS_Eyes GCS_Motor GCS_ Verbal TotaalScore Toelichting
08-02-2013 6:43 2 4 5 11 Beste score voor intubatie, kleding stond in brand
GlasgowComa ScaleDatumTijd GCS_Eyes GCS_Motor GCS_ Verbal TotaalScore Toelichting
07-02-2013 11:34 4 4 1 Lijkt adequaat
GlasgowComa ScaleDatumTijd GCS_Eyes GCS_Motor GCS_ Verbal TotaalScore Toelichting
07-02-2013 8:00 1 1 1 3 Zonder spierverslappers na 2 uur reanimatie

References

1. openEHR-EHR-OBSERVATION.glasgow_coma.v1[Online] Beschikbaar op: http://www.openehr.org/knowledge/ [Geraadpleegd: 23 februari 2015].

2. Glasgow Coma Schaal [Online] Beschikbaar op: http://www.tabellenboekje.nl/menselijk-lichaam-tabel-glasgow-coma-schaal.php#glasgow-coma-schaal-volwassen [Geraadpleegd: 23 februari 2015].

Valuesets

GCS_EyesCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.1
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Spontaneous E4 4 GCS_Eyes 2.16.840.1.113883.2.4.3.11.60.40.4.2.1 Spontaan [De ogen worden spontaan geopend]
To verbal stimuli, command, speech E3 3 GCS_Eyes 2.16.840.1.113883.2.4.3.11.60.40.4.2.1 Bij aanspreken of aanroepen [De ogen worden pas geopend op aanspreken van de patiënt]
To pain only E2 2 GCS_Eyes 2.16.840.1.113883.2.4.3.11.60.40.4.2.1 Bij pijn [De ogen worden pas geopend bij een pijnprikkel]
No response E1 1 GCS_Eyes 2.16.840.1.113883.2.4.3.11.60.40.4.2.1 Geen reactie [De ogen blijven gesloten]

GCS_MotorCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.2
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Obeys M6 6 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Voert opdracht uit [Een eenvoudig bevel wordt uitgevoerd]
Localises pain M5 5 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Lokaliseren [In staat zijn de pijn duidelijk te localiseren]
Withdrawal response M4 4 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Terugtrekken [In staat om een afwerende of wegtrekkende beweging te maken op een pijnprikkel]
Flexor response M3 3 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Buigreactie [Armen en handen op krampachtige manier geplooid. Meestal benen gestrekt.]
Extensor response M2 2 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Strekreactie [Armen en handen op krampachtige manier geplooid met naar buitengedraaide hand. Mogelijk alle spieren van het lichaam gespannen]
No response M1 1 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Geen reactie op pijnprikkel [Geen enkele lichamelijke reactie op een pijnprikkel]

GCS_VerbalCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.5
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Oriented V5 5 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Lachen en huilen [Lacht of huilt zachtjes]
Confused V4 4 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Huilen [Huilt en is onpasselijk]
Inappropriate speech V3 3 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Niet adequaat huilen [Aanhoudend huilen of krijsen]
Incomprehensible sounds V2 2 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Kreunen [Kreunen en onrustig/rusteloos]
No response V1 1 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Geen reactie [Geen enkel verbale response]

GCS_VerbalCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.4
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Oriented V5 5 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Adequate woorden en zinnen [Woorden of kleine zinnen in context van de situatie]
Confused V4 4 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Onjuiste woorden [Verwarde woorden]
Inappropriate speech V3 3 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Huilen [Aanhoudend huilen of krijsen]
Incomprehensible sounds V2 2 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Kreunen [Alleen kreunen]
No response V1 1 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Geen reactie [Geen enkel verbale response]

GCS_VerbalCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.3
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Oriented V5 5 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Georiënteerd [Helder en duidelijk bewust van de situatie]
Confused V4 4 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Verward [Verwarde conversatie maar wel in staat om te antwoorden op de vragen]
Inappropriate speech V3 3 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Inadequaat [Woorden zijn te verstaan maar vormen geen zinnen]
Incomprehensible sounds V2 2 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Onverstaanbaar [De spraak is niet te verstaan]
No response V1 1 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Geen reactie [Geen enkel verbale response]


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About this information

The information in this wikipage is based on Registratie aan de bron publication 2015 including errata dd. 16-07-2015
Conditions for use are located on the mainpage List2.png
This page is generated on 24/01/2018 17:12:20

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