GlasgowComaScale-v3.1(2018EN): verschil tussen versies

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Geen bewerkingssamenvatting
Regel 183: Regel 183:
==Information Model==
==Information Model==
<BR>
<BR>
<imagemap> Bestand:GlasgowComaScale-v3.1Model(EN).png | center  
<imagemap> Bestand:GlasgowComaScale-v3.1Model(2018EN).png | center  
rect 646 434 798 475 [[#GCS_VerbalCodelistBaby]]
rect 656 442 808 483 [[#GCS_VerbalCodelijstBaby]]
rect 646 377 808 418 [[#GCS_VerbalCodelistToddler]]
rect 656 385 818 426 [[#GCS_VerbalCodelijstKleuter]]
rect 254 121 360 223 [[#9347]]
rect 264 129 370 231 [[#9347]]
rect 234 404 386 474 [[#9345]]
rect 244 412 396 482 [[#9345]]
rect 46 204 178 274 [[#9346]]
rect 56 212 188 282 [[#9346]]
rect 646 320 774 361 [[#GCS_VerbalCodelist]]
rect 656 328 784 369 [[#GCS_VerbalCodelijst]]
rect 468 362 584 432 [[#9352]]
rect 478 370 594 440 [[#9352]]
rect 646 254 774 295 [[#GCS_MotorCodelist]]
rect 656 262 784 303 [[#GCS_MotorCodelijst]]
rect 646 150 774 191 [[#GCS_EyesCodelist]]
rect 656 158 784 199 [[#GCS_EyesCodelijst]]
rect 468 237 584 307 [[#9350]]
rect 478 245 594 315 [[#9350]]
rect 468 139 584 209 [[#9348]]
rect 478 147 594 217 [[#9348]]
rect 253 275 361 355 [[#9344]]
rect 263 283 371 363 [[#9344]]
rect 46 302 178 372 [[#12771]]
rect 56 310 188 380 [[#12771]]
rect 25 414 212 464 [[#ConditionsDuringMeasurementCodelist]]
rect 35 422 222 472 [[#ConditiesTijdensMetingCodelijst]]
desc none
desc none
</imagemap>
</imagemap>
Regel 207: Regel 207:
|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=9344 Title="NL: GlasgowComaScale">[[Bestand: arrowdown.png | 10px | link=]]GlasgowComaScale</span>
|colspan ="6" style ="padding-left: 0px"|<span Id=9344 Title="EN: 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 220: Regel 220:
||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=9345 Title="NL: GlasgowComaScaleDatumTijd">[[Bestand: arrowright.png | 10px | link=]]GlasgowComaScaleDateTime</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=9345 Title="EN: GlasgowComaScaleDateTime">[[Bestand: arrowright.png | 10px | link=]]GlasgowComaScaleDatumTijd</span>
|1
|1
|Time at which the EMV score was determined.
|Time at which the EMV score was determined.
Regel 229: Regel 229:
||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=9348 Title="NL: GCS_Eyes">[[Bestand: arrowright.png | 10px | link=]]GCS_Eyes</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=9348 Title="EN: 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 240: Regel 240:
{|
{|
|-
|-
|[[Bestand: List2.png | link=#GCS_EyesCodelist]]||[[#GCS_EyesCodelist|GCS_EyesCodelist]]
|[[Bestand: List2.png | link=#GCS_EyesCodelijst]]||[[#GCS_EyesCodelijst|GCS_EyesCodelijst]]
|}
|}
|-style="vertical-align:top; background-color: transparent; "
|-style="vertical-align:top; background-color: transparent; "
Regel 246: Regel 246:
||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=9350 Title="NL: GCS_Motor">[[Bestand: arrowright.png | 10px | link=]]GCS_Motor</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=9350 Title="EN: 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 257: Regel 257:
{|
{|
|-
|-
|[[Bestand: List2.png | link=#GCS_MotorCodelist]]||[[#GCS_MotorCodelist|GCS_MotorCodelist]]
|[[Bestand: List2.png | link=#GCS_MotorCodelijst]]||[[#GCS_MotorCodelijst|GCS_MotorCodelijst]]
|}
|}
|-style="vertical-align:top; background-color: transparent; "
|-style="vertical-align:top; background-color: transparent; "
Regel 263: Regel 263:
||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=9352 Title="NL: GCS_Verbal">[[Bestand: arrowright.png | 10px | link=]]GCS_Verbal</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=9352 Title="EN: 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 274: Regel 274:
{|
{|
|-
|-
|[[Bestand: List2.png | link=#GCS_VerbalCodelist]]||[[#GCS_VerbalCodelist|GCS_VerbalCodelist]]
|[[Bestand: List2.png | link=#GCS_VerbalCodelijst]]||[[#GCS_VerbalCodelijst|GCS_VerbalCodelijst]]
|-
|-
|[[Bestand: List2.png | link=#GCS_VerbalCodelistBaby]]||[[#GCS_VerbalCodelistBaby|GCS_VerbalCodelistBaby]]
|[[Bestand: List2.png | link=#GCS_VerbalCodelijstBaby]]||[[#GCS_VerbalCodelijstBaby|GCS_VerbalCodelijstBaby]]
|-
|-
|[[Bestand: List2.png | link=#GCS_VerbalCodelistToddler]]||[[#GCS_VerbalCodelistToddler|GCS_VerbalCodelistToddler]]
|[[Bestand: List2.png | link=#GCS_VerbalCodelijstKleuter]]||[[#GCS_VerbalCodelijstKleuter|GCS_VerbalCodelijstKleuter]]
|}
|}
|-style="vertical-align:top; background-color: transparent; "
|-style="vertical-align:top; background-color: transparent; "
Regel 284: Regel 284:
||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=9347 Title="NL: TotaalScore">[[Bestand: arrowright.png | 10px | link=]]TotalScore</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=9347 Title="EN: TotalScore">[[Bestand: arrowright.png | 10px | link=]]TotaalScore</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 293: Regel 293:
||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=12771 Title="NL: ConditiesTijdensMeting">[[Bestand: arrowright.png | 10px | link=]]ConditionsDuringMeasurement</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=12771 Title="EN: ConditionsDuringMeasurement">[[Bestand: arrowright.png | 10px | link=]]ConditiesTijdensMeting</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 300: Regel 300:
{|
{|
|-
|-
|[[Bestand: List2.png | link=#ConditionsDuringMeasurementCodelist]]||[[#ConditionsDuringMeasurementCodelist|ConditionsDuringMeasurementCodelist]]
|[[Bestand: List2.png | link=#ConditiesTijdensMetingCodelijst]]||[[#ConditiesTijdensMetingCodelijst|ConditiesTijdensMetingCodelijst]]
|}
|}
|-style="vertical-align:top; background-color: transparent; "
|-style="vertical-align:top; background-color: transparent; "
Regel 306: Regel 306:
||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=9346 Title="NL: Toelichting">[[Bestand: arrowright.png | 10px | link=]]Comment</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=9346 Title="EN: Comment">[[Bestand: arrowright.png | 10px | link=]]Toelichting</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 387: Regel 387:


== Valuesets ==
== Valuesets ==
=== ConditionsDuringMeasurementCodelist===
=== ConditiesTijdensMetingCodelijst===
{| class="wikitable" width="60%"  
{| class="wikitable" width="60%"  
|-style='vertical-align:top; background-color: #E8D7BE;'
|-style='vertical-align:top; background-color: #E8D7BE;'
Regel 400: Regel 400:
|Description<!--vsDescription-->
|Description<!--vsDescription-->
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Gesedeerd" >Sedated</span>
|<span title = "Gesedeerd">Sedated</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=17971005 17971005]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=17971005 17971005]
|SNOMED CT
|SNOMED CT
Regel 412: Regel 412:
|spierverslappers
|spierverslappers
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Afasie" >Aphasia</span>
|<span title = "Afasie">Aphasia</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=87486003 87486003]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=87486003 87486003]
|SNOMED CT
|SNOMED CT
Regel 424: Regel 424:
|tube aanwezig
|tube aanwezig
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Aanwezigheid van tracheostoma" >Tracheostomy present</span>
|<span title = "Aanwezigheid van tracheostoma">Tracheostomy present</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=302108003 302108003]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=302108003 302108003]
|SNOMED CT
|SNOMED CT
Regel 436: Regel 436:
|anders
|anders
|}
|}
=== GCS_EyesCodelist===
=== GCS_EyesCodelijst===
{| class="wikitable" width="60%"  
{| class="wikitable" width="60%"  
|-style='vertical-align:top; background-color: #E8D7BE;'
|-style='vertical-align:top; background-color: #E8D7BE;'
Regel 478: Regel 478:
|Geen reactie [De ogen blijven gesloten]
|Geen reactie [De ogen blijven gesloten]
|}
|}
=== GCS_MotorCodelist===
=== GCS_MotorCodelijst===
{| class="wikitable" width="60%"  
{| class="wikitable" width="60%"  
|-style='vertical-align:top; background-color: #E8D7BE;'
|-style='vertical-align:top; background-color: #E8D7BE;'
Regel 534: Regel 534:
|Geen reactie op pijnprikkel [Geen enkele lichamelijke reactie op een pijnprikkel]
|Geen reactie op pijnprikkel [Geen enkele lichamelijke reactie op een pijnprikkel]
|}
|}
=== GCS_VerbalCodelist===
=== GCS_VerbalCodelijst===
{| class="wikitable" width="60%"  
{| class="wikitable" width="60%"  
|-style='vertical-align:top; background-color: #E8D7BE;'
|-style='vertical-align:top; background-color: #E8D7BE;'
Regel 583: Regel 583:
|Geen reactie [Geen enkel verbale response]
|Geen reactie [Geen enkel verbale response]
|}
|}
=== GCS_VerbalCodelistBaby===
=== GCS_VerbalCodelijstBaby===
{| class="wikitable" width="60%"  
{| class="wikitable" width="60%"  
|-style='vertical-align:top; background-color: #E8D7BE;'
|-style='vertical-align:top; background-color: #E8D7BE;'
Regel 632: Regel 632:
|Geen reactie [Geen enkel verbale response]
|Geen reactie [Geen enkel verbale response]
|}
|}
=== GCS_VerbalCodelistToddler===
=== GCS_VerbalCodelijstKleuter===
{| class="wikitable" width="60%"  
{| class="wikitable" width="60%"  
|-style='vertical-align:top; background-color: #E8D7BE;'
|-style='vertical-align:top; background-color: #E8D7BE;'
Regel 689: Regel 689:
====This information model refers to<!--ftRefersTo-->====
====This information model refers to<!--ftRefersTo-->====
:--
:--
====This inforation model is used in<!--ftReferredBy-->====
====This information model is used in<!--ftReferredBy-->====
:--
:--
==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->==
==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->==
Regel 708: Regel 708:
</ul>
</ul>
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
This page is generated on 01/11/2018 17:35:18 with ZibExtraction v. 2.0.6879.31307<!--ftDate--> <BR>
This page is generated on 23/12/2018 00:46:55 with ZibExtraction v. 3.0.6929.24609<!--ftDate--> <BR>
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<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2018(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2018(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div>
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2018(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2018(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div>

Versie van 24 dec 2018 11:57


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: 3.1
HCIM Status:Final
Release: 2018
Release status: Prepublished
Release date: 01-10-2018

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 01-10-2018
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 31-12-2017
DCM::Superseeds nl.zorg.GlasgowComaScale-v3.0
DCM::Version 3.1
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

Publicatieversie 3.0 (01-05-2016)

Publicatieversie 3.1 (04-09-2017)

ZIB-431 Gebruik van LOINC en SNOMED CT in vitale functies gerelateerde zorginformatiebouwstenen
ZIB-466 Uitbreiding met dataelement "ConditiesTijdensMeting"
ZIB-564 Aanpassing/harmonisatie Engelse conceptnamen

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 VerbalCodelijstBaby#GCS VerbalCodelijstKleuter#9347#9345#9346#GCS VerbalCodelijst#9352#GCS MotorCodelijst#GCS EyesCodelijst#9350#9348#9344#12771#ConditiesTijdensMetingCodelijstGlasgowComaScale-v3.1Model(2018EN).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.pngGlasgowComaScaleDatumTijd 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_EyesCodelijst
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 Score motor response subscore
List2.png GCS_MotorCodelijst
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 Score verbal response subscore
List2.png GCS_VerbalCodelijst
List2.png GCS_VerbalCodelijstBaby
List2.png GCS_VerbalCodelijstKleuter
INT.png NL-CM:12.8.10 Arrowright.pngTotaalScore 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.
CD.png NL-CM:12.8.11 Arrowright.pngConditiesTijdensMeting 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 ConditiesTijdensMetingCodelijst
ST.png NL-CM:12.8.9 Arrowright.pngToelichting 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

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

ConditiesTijdensMetingCodelijst

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_EyesCodelijst

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.1 Binding: Extensible
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_MotorCodelijst

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.2 Binding: Extensible
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_VerbalCodelijst

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.3 Binding: Extensible
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]

GCS_VerbalCodelijstBaby

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.5 Binding: Extensible
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_VerbalCodelijstKleuter

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.4 Binding: Extensible
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]

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About this information

The information in this wikipage is based on Prerelease 2018 #1
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms version: 20180731 [R] (July 2018 Release)
  • LOINC version 2.64

Conditions for use are located on the mainpage List2.png
This page is generated on 23/12/2018 00:46:55 with ZibExtraction v. 3.0.6929.24609

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