GlasgowComaScale-v3.0(2016EN)

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General information

Name: nl.zorg.GlasgowComaScale
Version: 3.0
HCIM Status:Final
Release: 2016
Release status: Published
Release date: 1-5-2016

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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	1-5-2016
DCM::PublicationStatus	Published
DCM::ReviewerList	Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate	16-7-2015
DCM::Superseeds	nl.nfu.GlasgowComaScale-v1.2.1
DCM::Version	3.0
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)

.

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:

opening eyes (eye response);
answering questions (verbal response);
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

Type

Id

Concept

Card.

Definition

DefinitionCode

Reference

NL-CM:12.8.1

GlasgowComaScale

Root concept of the GlasgowComaScale information model. This root concept contains all data elements of the GlasgowComaScale information model.

386554004 Glasgow coma scale (assessment scale)

NL-CM:12.8.8

GlasgowComaScaleDateTime

1

Time at which the EMV score was determined.

NL-CM:12.8.2

GCS_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)

GCS_EyesCodelist

NL-CM:12.8.3

ExplanationEScore

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.

NL-CM:12.8.4

GCS_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

GCS_MotorCodelist

NL-CM:12.8.5

ExplanationMScore

0..1

Reason why no motor response test could be done. This is to be entered as free text.

NL-CM:12.8.6

GCS_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)

	GCS_VerbalCodelist
	GCS_VerbalCodelist
	GCS_VerbalCodelist

NL-CM:12.8.7

ExplanationVScore

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.

NL-CM:12.8.10

TotalScore

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.

NL-CM:12.8.9

Explanation

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

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	Binding:

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	Binding:

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	Binding:

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	Binding:

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	Binding:

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 Release summer 2016
Conditions for use are located on the mainpage
This page is generated on 21/12/2018 15:39:05 with ZibExtraction v. 3.0.6929.24609

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GlasgowComaScale-v3.0(2016EN)

Inhoud

General information

Metadata

Revision History

Concept

Purpose

Evidence Base

Information Model

Example Instances

References