GlasgowComaScale-v3.3(2022EN): verschil tussen versies

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Geen bewerkingssamenvatting
 
(2 tussenliggende versies door dezelfde gebruiker niet weergegeven)
Regel 8: Regel 8:
Release<!--hdPublication-->: '''2022''' <br>
Release<!--hdPublication-->: '''2022''' <br>
Release status<!--hdPublicationStatus-->: Prepublished<br>
Release status<!--hdPublicationStatus-->: Prepublished<br>
Release date<!--hdPublicationDate-->: 10-06-2022
Release date<!--hdPublicationDate-->: 15-10-2023
<!-- Aanroep Errata transclude page -->
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{{ErrataEN<!--hdErrata-->|2022|{{PAGENAME}}}}
{{ErrataEN<!--hdErrata-->|2022|{{PAGENAME}}}}
Regel 26: Regel 26:
|style="width:250px; "|DCM::ContactInformation.Telecom||*
|style="width:250px; "|DCM::ContactInformation.Telecom||*
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|style="width:250px; "|DCM::ContentAuthorList||Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
|style="width:250px; "|DCM::ContentAuthorList||Projectgroep Generieke Overdrachtsgegevens &amp; Kerngroep Registratie aan de Bron
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|style="width:250px; "|DCM::CreationDate||29-11-2012
|style="width:250px; "|DCM::CreationDate||29-11-2012
Regel 50: Regel 50:
|style="width:250px; "|DCM::Name||nl.zorg.GlasgowComaScale
|style="width:250px; "|DCM::Name||nl.zorg.GlasgowComaScale
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|style="width:250px; "|DCM::PublicationDate||10-06-2022
|style="width:250px; "|DCM::PublicationDate||15-10-2023
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|style="width:250px; "|DCM::PublicationStatus||Prepublished
|style="width:250px; "|DCM::PublicationStatus||Prepublished
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|style="width:250px; "|DCM::ReviewerList||Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
|style="width:250px; "|DCM::ReviewerList||Projectgroep Generieke Overdrachtsgegevens &amp; Kerngroep Registratie aan de Bron
|-  
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|style="width:250px; "|DCM::RevisionDate||28-10-2021
|style="width:250px; "|DCM::RevisionDate||28-10-2021
Regel 77: Regel 77:
<u>Publicatieversie 1.2</u> (01-04-2015)
<u>Publicatieversie 1.2</u> (01-04-2015)
{|
{|
|-
Issue summaries niet beschikbaar<BR>
|style="width:75px; "|[[ZIBIssues500_0#ZIB-227 | ZIB-227 ]]
Bevat: ZIB-227, ZIB-228, ZIB-229, ZIB-230, ZIB-231, ZIB-232, ZIB-308, ZIB-311, ZIB-361.
|DCM::Name van klinische bouwsteen OverdrachtGlasgowComaScale aangepast van nl.nfu.OverdrachtScoreBewustzijn naar nl.nfu.OverdrachtGlasgowComaScale.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-228 | ZIB-228 ]]
|De naam van de waardenlijst GCS_VerbalCodelijstBaby van concept GCS_Verbal kwam niet overeen met de tagged value.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-229 | ZIB-229 ]]
|De naam van de waardenlijst GCS_VerbalCodelijstKleuter van concept GCS_Verbal kwam niet overeen met de tagged value.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-230 | ZIB-230 ]]
|De naam van de waardenlijst GCS_VerbalCodelijst van concept GCS_Verbal kwam niet overeen met de tagged value.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-231 | ZIB-231 ]]
|De naam van de waardenlijst GCS_EyesCodelijst van concept GCS_Eyes kwam niet overeen met de tagged value.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-232 | ZIB-232 ]]
|De naam van de waardenlijst GCS_MotorCodelijst van concept GCS_Motor kwam niet overeen met de tagged value.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-308 | ZIB-308 ]]
|Prefix Overdracht weggehaald bij de generieke bouwstenen
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-311 | ZIB-311 ]]
|waardebereik TotaalScore
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-361 | ZIB-361 ]]
|Naamgeving concept Opmerking aangepast
|}
|}


Incl. algemene wijzigingsverzoeken:  
Incl. algemene wijzigingsverzoeken:  
{|
ZIB-94, ZIB-154, ZIB-200, ZIB-201, ZIB-309, ZIB-324, ZIB-326.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-94 | ZIB-94 ]]
|Aanpassen tekst van Disclaimer, Terms of Use & Copyrights
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-154 | ZIB-154 ]]
|Consequenties opsplitsing Medicatie bouwstenen voor overige bouwstenen.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-200 | ZIB-200 ]]
|Naamgeving SNOMED CT in tagged values klinische bouwstenen gelijk getrokken.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-201 | ZIB-201 ]]
|Naamgeving OID: in tagged value notes van klinische bouwstenen gelijk getrokken.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-309 | ZIB-309 ]]
|EOI aangepast
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-324 | ZIB-324 ]]
|Codelijsten Name en Description beginnen met een Hoofdletter
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-326 | ZIB-326 ]]
|Tekstuele aanpassingen conform de kwaliteitsreview kerngroep 2015
|}


<u>Publicatieversie 1.2.1</u> (16-07-2015)
<u>Publicatieversie 1.2.1</u> (16-07-2015)
{|
Bevat: ZIB-414.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-414 | ZIB-414 ]]
|Richting relatie tussen constraints en waardelijsten is fout
|}


<u>Publicatieversie 3.0</u> (01-05-2016)
<u>Publicatieversie 3.0</u> (01-05-2016)
{|
Bevat: ZIB-453
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-453 | ZIB-453 ]]
|Wijziging naamgeving ZIB's en logo's door andere opzet van beheer
|}


<u>Publicatieversie 3.1</u> (04-09-2017)
<u>Publicatieversie 3.1</u> (04-09-2017)
{|
Bevat: ZIB-431, ZIB-466, ZIB-564.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-431 | ZIB-431 ]]
|Gebruik van LOINC en SNOMED CT in vitale functies gerelateerde zorginformatiebouwstenen
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-466 | ZIB-466 ]]
|Uitbreiding met dataelement "ConditiesTijdensMeting"
|-
|style="width:75px; "|[[ZIBIssues500_1#ZIB-564 | ZIB-564 ]]
|Aanpassing/harmonisatie Engelse conceptnamen
|}


Publicatieversie <u>3.2</u> (01-09-2020)
Publicatieversie <u>3.2</u> (01-09-2020)
{|
Bevat: ZIB-1050, ZIB-1085.
|-
|style="width:75px; "|[[ZIBIssues500_2#ZIB-1050 | ZIB-1050 ]]
|Total score codering voor GCS
|-
|style="width:75px; "|[[ZIBIssues500_2#ZIB-1085 | ZIB-1085 ]]
|aanpassen en actualiseren codelijsten GCS (o.a. voor baby en peuter)
|}


Publicatieversie <u>3.3</u> (01-12-2021)
Publicatieversie <u>3.3</u> (01-12-2021)
{|
Bevat: ZIB-1314.
|-
|style="width:75px; "|[[ZIBIssues500_2#ZIB-1314 | ZIB-1314 ]]
|GCS_VerbalCodelijstBaby en Kleuter hebben verschillende V10
|}
</div>
</div>


Regel 208: Regel 132:
<imagemap> Bestand:GlasgowComaScale-v3.3Model(2022EN).png | center  
<imagemap> Bestand:GlasgowComaScale-v3.3Model(2022EN).png | center  
rect 35 422 222 472 [[#ConditionsDuringMeasurementCodelist]]
rect 35 422 222 472 [[#ConditionsDuringMeasurementCodelist]]
rect 56 310 188 380 [[#13803]]
rect 56 310 188 380 [[#1885]]
rect 643 442 795 483 [[#GCS_VerbalCodelistBaby]]
rect 643 442 795 483 [[#GCS_VerbalCodelistBaby]]
rect 643 385 795 426 [[#GCS_VerbalCodelistToddler]]
rect 643 385 795 426 [[#GCS_VerbalCodelistToddler]]
rect 263 132 369 234 [[#13811]]
rect 263 132 369 234 [[#1907]]
rect 244 412 396 482 [[#13806]]
rect 244 412 396 482 [[#1888]]
rect 56 212 188 282 [[#13812]]
rect 56 212 188 282 [[#1908]]
rect 642 326 794 367 [[#GCS_VerbalCodelist]]
rect 642 326 794 367 [[#GCS_VerbalCodelist]]
rect 478 370 594 440 [[#13805]]
rect 478 370 594 440 [[#1887]]
rect 642 166 794 207 [[#GCS_MotorCodelist]]
rect 642 166 794 207 [[#GCS_MotorCodelist]]
rect 643 91 795 132 [[#GCS_EyesCodelist]]
rect 643 91 795 132 [[#GCS_EyesCodelist]]
rect 478 203 594 273 [[#13801]]
rect 478 203 594 273 [[#1883]]
rect 478 77 594 147 [[#13800]]
rect 478 77 594 147 [[#1882]]
rect 267 282 375 362 [[#13799]]
rect 267 282 375 362 [[#1881]]
rect 643 217 795 258 [[#GCS_MotorCodelistToddler]]
rect 643 217 795 258 [[#GCS_MotorCodelistToddler]]
rect 643 274 795 315 [[#GCS_MotorCodelistBaby]]
rect 643 274 795 315 [[#GCS_MotorCodelistBaby]]
Regel 232: Regel 156:
|style = "text-align:center" |[[Bestand: block.png| 20px | link=]]
|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 Id=13799 Title="NL: GlasgowComaScale">[[Bestand: arrowdown.png | 10px | link=]]GlasgowComaScale</span>
|colspan ="6" style ="padding-left: 0px"|<span Id=1881 Title="NL: GlasgowComaScale">[[Bestand: arrowdown.png | 10px | link=]]GlasgowComaScale</span>
|
|
|Root concept of the GlasgowComaScale information model. This root concept contains all data elements of the GlasgowComaScale information model.
|Root concept of the GlasgowComaScale information model. This root concept contains all data elements of the GlasgowComaScale information model.
Regel 245: Regel 169:
||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 Id=13806 Title="NL: GlasgowComaScaleDatumTijd">[[Bestand: arrowright.png | 10px | link=]]GlasgowComaScaleDateTime</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=1888 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 254: Regel 178:
||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 Id=13800 Title="NL: GCS_Eyes">[[Bestand: arrowright.png | 10px | link=]]GCS_Eyes</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=1882 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 ConditionsDuringMeasurement 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 ConditionsDuringMeasurement concept.
Regel 271: Regel 195:
||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 Id=13801 Title="NL: GCS_Motor">[[Bestand: arrowright.png | 10px | link=]]GCS_Motor</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=1883 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 ConditionsDuringMeasurement 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 ConditionsDuringMeasurement concept.
Regel 292: Regel 216:
||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 Id=13805 Title="NL: GCS_Verbal">[[Bestand: arrowright.png | 10px | link=]]GCS_Verbal</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=1887 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 ConditionsDuringMeasurement 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 ConditionsDuringMeasurement concept.
Regel 313: Regel 237:
||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 Id=13811 Title="NL: TotaalScore">[[Bestand: arrowright.png | 10px | link=]]TotalScore</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=1907 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 326: Regel 250:
||NL-CM:12.8.11
||NL-CM:12.8.11
|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 Id=13803 Title="NL: ConditiesTijdensMeting">[[Bestand: arrowright.png | 10px | link=]]ConditionsDuringMeasurement</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=1885 Title="NL: ConditiesTijdensMeting">[[Bestand: arrowright.png | 10px | link=]]ConditionsDuringMeasurement</span>
|0..*
|0..*
|Conditions during the measurement that prevent one or more of the subscores from being determined (non testable), such as,e.g. intubation during testing of GCS_Verbal.
|Conditions during the measurement that prevent one or more of the subscores from being determined (non testable), such as,e.g. intubation during testing of GCS_Verbal.
Regel 339: Regel 263:
||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 Id=13812 Title="NL: Toelichting">[[Bestand: arrowright.png | 10px | link=]]Comment</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=1908 Title="NL: Toelichting">[[Bestand: arrowright.png | 10px | link=]]Comment</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 345: Regel 269:
{|
{|
|-
|-
|<span title = "Codesystem: LOINC (Nar)" >[https://terminologie.nictiz.nl/art-decor/loinc?conceptId=48767-8 48767-8] Annotation comment [Interpretation] Narrative</span>
|<span title = "Codesystem: LOINC; Verklarend commentaar [interpretatie] in {systeem} (Nar)" >[https://terminologie.nictiz.nl/art-decor/loinc?conceptId=48767-8 48767-8] Annotation comment [Interpretation] Narrative</span>
|}
|}
|
|
Regel 355: Regel 279:
''Only available in Dutch<!--noTranslation-->''
''Only available in Dutch<!--noTranslation-->''


{|class="wikitable" width="780px" style= "font-size: 9.5pt;"
Voorbeeld file fout: Unable to find the specified file. : nl.zorg.GlasgowComaScale-v3.3(NL)_Voorbeeld.docx
|-style=vertical-align:top;
| style="background-color: #1F497D; width: 19%; "|<font color=#FFFFFF><b>GlasgowComa</b></font><font color=#FFFFFF><b> </b></font><font color=#FFFFFF><b>ScaleDatumTijd</b></font>
| style="background-color: #1F497D; width: 7%; "|<font color=#FFFFFF><b>GCS_Eyes</b></font>
| style="background-color: #1F497D; width: 9%; "|<font color=#FFFFFF><b>GCS_Motor</b></font>
| 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%; "|<font color=#FFFFFF><b>TotaalScore</b></font>
| style="background-color: #1F497D; width: 42%; "|<font color=#FFFFFF><b>Toelichting</b></font>
|-style=vertical-align:top;
| style="width: 19%; "|08-02-2013 6:43
| style="width: 7%; "|2
| style="width: 9%; "|4
| style="width: 9%; "|5
| style="width: 15%; "|11
| style="width: 42%; "|Beste score voor intubatie, kleding stond in brand
|-style=vertical-align:top;
| style="width: 19%; "|
| style="width: 7%; "|
| style="width: 9%; "|
| style="width: 9%; "|
| style="width: 15%; "|
| style="width: 42%; "|
|-style=vertical-align:top;
| style="background-color: #1F497D; width: 19%; "|<font color=#FFFFFF><b>GlasgowComa</b></font><font color=#FFFFFF><b> </b></font><font color=#FFFFFF><b>ScaleDatumTijd</b></font>
| style="background-color: #1F497D; width: 7%; "|<font color=#FFFFFF><b>GCS_Eyes</b></font>
| style="background-color: #1F497D; width: 9%; "|<font color=#FFFFFF><b>GCS_Motor</b></font>
| 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%; "|<font color=#FFFFFF><b>TotaalScore</b></font>
| style="background-color: #1F497D; width: 42%; "|<font color=#FFFFFF><b>Toelichting</b></font>
|-style=vertical-align:top;
| style="width: 19%; "|07-02-2013 11:34
| style="width: 7%; "|4
| style="width: 9%; "|4
| style="width: 9%; "|NT
| style="width: 15%; "|
| style="width: 42%; "|patiënt is doof
|-style=vertical-align:top;
| style="width: 19%; "|
| style="width: 7%; "|
| style="width: 9%; "|
| style="width: 9%; "|
| style="width: 15%; "|
| style="width: 42%; "|
|-style=vertical-align:top;
| style="background-color: #1F497D; width: 19%; "|<font color=#FFFFFF><b>GlasgowComa</b></font><font color=#FFFFFF><b> </b></font><font color=#FFFFFF><b>ScaleDatumTijd</b></font>
| style="background-color: #1F497D; width: 7%; "|<font color=#FFFFFF><b>GCS_Eyes</b></font>
| style="background-color: #1F497D; width: 9%; "|<font color=#FFFFFF><b>GCS_Motor</b></font>
| 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%; "|<font color=#FFFFFF><b>TotaalScore</b></font>
| style="background-color: #1F497D; width: 42%; "|<font color=#FFFFFF><b>Toelichting</b></font>
|-style=vertical-align:top;
| style="width: 19%; "|07-02-2013 8:00
| style="width: 7%; "|1
| style="width: 9%; "|1
| style="width: 9%; "|1
| style="width: 15%; "|3
| style="width: 42%; "|Zonder spierverslappers na 2 uur reanimatie
|}
 
==References==
==References==
<ol>
<ol>
Regel 498: Regel 364:
|GCS_Eyes
|GCS_Eyes
|2.16.840.1.113883.2.4.3.11.60.40.4.2.1
|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]
|Bij aanspreken of aanroepen [De ogen worden pas geopend op aanspreken van de pati&#235;nt]
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Op prikkel">To stimuli</span>
|<span title = "Op prikkel">To stimuli</span>
Regel 724: Regel 590:
|Description<!--vsDescription-->
|Description<!--vsDescription-->
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Georiënteerd">Oriented</span>
|<span title = "Geori&#235;nteerd">Oriented</span>
|[https://zibs.nl/wiki/Zib_Codestelsels#Codestelsels_voor_waardelijsten V5]
|[https://zibs.nl/wiki/Zib_Codestelsels#Codestelsels_voor_waardelijsten V5]
|5
|5
|GCS_Verbal
|GCS_Verbal
|2.16.840.1.113883.2.4.3.11.60.40.4.2.3
|2.16.840.1.113883.2.4.3.11.60.40.4.2.3
|Georiënteerd [Helder en duidelijk bewust van de situatie]
|Geori&#235;nteerd [Helder en duidelijk bewust van de situatie]
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Verward">Confused</span>
|<span title = "Verward">Confused</span>
Regel 836: Regel 702:
|Description<!--vsDescription-->
|Description<!--vsDescription-->
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Georiënteerd">Oriented</span>
|<span title = "Geori&#235;nteerd">Oriented</span>
|[https://zibs.nl/wiki/Zib_Codestelsels#Codestelsels_voor_waardelijsten V5]
|[https://zibs.nl/wiki/Zib_Codestelsels#Codestelsels_voor_waardelijsten V5]
|5
|5
Regel 889: Regel 755:
:--
:--
==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->==
==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->==
To exchange information based on health and care information models, additional, more technical specifications are required.<BR>
To exchange information based on health and care information models, additional, more technical specifications are required.&lt;BR&gt;
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro-->
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro-->
<ul>
<ul>
<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> {{ArtDecorLinks|2022|12.8}}</li>
<li>HL7&#174; version 3 CDA compatible specifications, available through the Nictiz ART-DECOR&#174; environment<!--ftArtDecorReference--> {{ArtDecorLinks|2022|12.8}}</li>
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</ul>
</ul>
==Downloads<!--ftDownloadTitle-->==
==Downloads<!--ftDownloadTitle-->==
Regel 901: Regel 767:
SNOMED CT and LOINC codes are based on:
SNOMED CT and LOINC codes are based on:
<ul>
<ul>
<li>SNOMED Clinical Terms version: 20220131 [R] (January 2022 Release)</li>
<li>SNOMED Clinical Terms versie: 20230930 [R] (september 2023-editie)</li>
<li>LOINC version 2.67</li>
<li>LOINC version 2.76</li>
</ul>
</ul>
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Huidige versie van 27 mrt 2024 om 11:24


Attention!! This is not the most recent version of this information model. You can find the most recent version ''here''.

General information

Name: nl.zorg.GlasgowComaScale NL.png
Version: 3.3
HCIM Status:Final
Release: 2022
Release status: Prepublished
Release date: 15-10-2023

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 PM
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.zorg.GlasgowComaScale
DCM::PublicationDate 15-10-2023
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 28-10-2021
DCM::Supersedes nl.zorg.GlasgowComaScale-v3.2
DCM::Version 3.3
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)

Issue summaries niet beschikbaar
Bevat: ZIB-227, ZIB-228, ZIB-229, ZIB-230, ZIB-231, ZIB-232, ZIB-308, ZIB-311, ZIB-361.

Incl. algemene wijzigingsverzoeken: ZIB-94, ZIB-154, ZIB-200, ZIB-201, ZIB-309, ZIB-324, ZIB-326.

Publicatieversie 1.2.1 (16-07-2015) Bevat: ZIB-414.

Publicatieversie 3.0 (01-05-2016) Bevat: ZIB-453

Publicatieversie 3.1 (04-09-2017) Bevat: ZIB-431, ZIB-466, ZIB-564.

Publicatieversie 3.2 (01-09-2020) Bevat: ZIB-1050, ZIB-1085.

Publicatieversie 3.3 (01-12-2021) Bevat: ZIB-1314.

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 NT), with an extra comment. Er moet dan GEEN totaalscore worden doorgegeven.
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 months: 10 and up
6-12 months : 11 and up
1-2 : 12 and up
2-5 : 13 and up
> 5 : 14 and up

Information Model


#ConditionsDuringMeasurementCodelist#1885#GCS VerbalCodelistBaby#GCS VerbalCodelistToddler#1907#1888#1908#GCS VerbalCodelist#1887#GCS MotorCodelist#GCS EyesCodelist#1883#1882#1881#GCS MotorCodelistToddler#GCS MotorCodelistBabyGlasgowComaScale-v3.3Model(2022EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:12.8.1 Arrowdown.pngGlasgowComaScale Root concept of the GlasgowComaScale information model. This root concept contains all data elements of the GlasgowComaScale information model.
35088-4 Glasgow coma 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 ConditionsDuringMeasurement concept.
281395000 Glasgow Coma Score eye opening subscore
List2.png GCS_EyesCodelist
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 ConditionsDuringMeasurement concept.
281396004 Glasgow Coma Scale motor response subscore
List2.png GCS_MotorCodelist
List2.png GCS_MotorCodelistBaby
List2.png GCS_MotorCodelistToddler
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 ConditionsDuringMeasurement concept.
281397008 Glasgow Coma Scale verbal response subscore
List2.png GCS_VerbalCodelijst
List2.png GCS_VerbalCodelijstBaby
List2.png GCS_VerbalCodelijstKleuter
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.
444323003 Modified Glasgow coma score
CD.png NL-CM:12.8.11 Arrowright.pngConditionsDuringMeasurement 0..* Conditions during the measurement that prevent one or more of the subscores from being determined (non testable), such as,e.g. intubation during testing of GCS_Verbal.
List2.png ConditionsDuringMeasurementCodelist
ST.png NL-CM:12.8.9 Arrowright.pngComment 0..1 Comment on (the context of) the EMV score measurement, such as any problems or factors that may influence interpretation.
48767-8 Annotation comment [Interpretation] Narrative

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

Voorbeeld file fout: Unable to find the specified file. : nl.zorg.GlasgowComaScale-v3.3(NL)_Voorbeeld.docx

References

  1. Glasgow Coma Scale (GCS) [Online] op https://www.openehr.org/ckm/ [Geraadpleegd: 22 mei 2020].
  2. Paediatric Glasgow Coma Scale (pGCS) [online] beschikbaar viahttps://www.openehr.org/ckm/ [Geraadpleegd: 22 mei 2020].
  3. Performance of the Pediatric Glasgow Coma Scale Score in the Evaluation of Children With Blunt Head Trauma, Dominic A. Borgialli, et. all. 2016 by the Society for Academic Emergency Medicine, doi: 10.1111/acem.13014
    4. <lihttps://www.glasgowcomascale.org [geraadpleegd: 22 mei 2020]

Valuesets

ConditionsDuringMeasurementCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.6 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Sedated 17971005 SNOMED CT 2.16.840.1.113883.6.96 gesedeerd
Paralysis caused by skeletal muscle relaxant 40241000146103 SNOMED CT 2.16.840.1.113883.6.96 spierverslappers
Aphasia 87486003 SNOMED CT 2.16.840.1.113883.6.96 afasie
Endotracheal tube present 419991009 SNOMED CT 2.16.840.1.113883.6.96 tube aanwezig
Tracheostomy present 302108003 SNOMED CT 2.16.840.1.113883.6.96 tracheostoma aanwezig
other OTH NullFlavor 2.16.840.1.113883.5.1008 anders

GCS_EyesCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.1 Binding: Required
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 geopend zonder aansporing
To sound 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 stimuli E2 2 GCS_Eyes 2.16.840.1.113883.2.4.3.11.60.40.4.2.1 Bij een prikkel [De ogen worden pas geopend na geven van een fysieke prikkel]
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 onder elke omstandigheid]
Not applicable NA 0 NullFlavor 2.16.840.1.113883.5.1008 Niet testbaar door een lokale beperkende factor

GCS_MotorCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.2 Binding: Required
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 lokaliseren]
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 buiten gedraaide 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 beweging op een pijnprikkel]
Not applicable NA 0 NullFlavor 2.16.840.1.113883.5.1008 Not applicable

GCS_MotorCodelistBaby

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.8 Binding: Required
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Moves spontaneously and purposefully M6B 6 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Normaal [beweegt zoals verwacht]
Withdraws to touch M5B 5 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Terugtrekken bij aanraking [Trekt terug bij aanraken]
Withdraws to pain M4B 4 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Terugtrekken in respons op pijn [Maakt afwerende of wegtrekkende beweging bij een pijnprikkel]
Flexor response M3 3 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Buigreactie [Langzame, buiging van armen en/of benen]
Extensor response M2 2 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Decerebrale strekreactie [strekken van armen en/of benen]
No response M1 1 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Geen beweging op prikkel [Geen enkele beweging op een prikkel]
Not applicable NA 0 NullFlavor 2.16.840.1.113883.5.1008 Niet van toepassing

GCS_MotorCodelistToddler

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.7 Binding: Required
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 tot bewegen uit [Een eenvoudig verzoek tot bewegen wordt uitgevoerd]
Localises pain M5 5 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Terugtrekken bij aanraking [Trekt terug bij aanraken]
Withdrawal response M4 4 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Terugtrekken in respons op pijn [Maakt afwerende of wegtrekkende beweging bij een pijnprikkel]
Flexor response M3 3 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Buigreactie [Langzame, buiging van armen en/of benen]
Extensor response M2 2 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Decerebrale strekreactie [strekken van armen en/of benen]
No response M1 1 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Geen beweging op prikkel [Geen enkele beweging op een prikkel]
Not applicable NA 0 NullFlavor 2.16.840.1.113883.5.1008 Niet van toepassing

GCS_VerbalCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.3 Binding: Required
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 respons]
Not applicable NA 0 NullFlavor 2.16.840.1.113883.5.1008 Not applicable

GCS_VerbalCodelistBaby

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.5 Binding: Required
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Coos/babbles V5B 5 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Kirt/brabbelt
Irritatable cries V4B 4 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Huilt prikkelbaar
Cries to pain V3B 3 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Huilt van de pijn
Moans V2B 2 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Jammert/kreunt
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]
Not applicable NA 0 NullFlavor 2.16.840.1.113883.5.1008 Not applicable

GCS_VerbalCodelistToddler

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.4 Binding: Required
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]
Not applicable NA 0 NullFlavor 2.16.840.1.113883.5.1008 Not applicable

This information model in other releases

Information model references

This information model refers to

--

This information model is used in

--

Technical specifications in HL7v3 CDA and HL7 FHIR

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:

  • HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment Artdecor.jpg
  • HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR Fhir.png

Downloads

This information model is also available as pdf file PDF.png or as spreadsheet Xlsx.png

About this information

The information in this wikipage is based on Pre-release 2022-1
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms versie: 20230930 [R] (september 2023-editie)
  • LOINC version 2.76

Conditions for use are located on the mainpage List2.png
This page is generated on 27/03/2024 11:09:32 with ZibExtraction v. 9.3.8851.20230

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