Be.en.hd.GlasgowComaScale

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General

Name: be.en.hd.GlasgowComaScale
Version: 0.0.1
Status: Draft

Metadata

DCM::CoderList healthdata.be
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Clinical Building Blocks Expert Group & healthdata.be
DCM::CreationDate 29-11-2012
DCM::DeprecatedDate
DCM::DescriptionLanguage en
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name healthdata.be
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 Draft
DCM::ModelerList Clinical Building Blocks Expert Group & healthdata.be
DCM::Name be.en.hd.GlasgowComaScale
DCM::PublicationDate
DCM::PublicationStatus
DCM::ReviewerList Clinical Building Blocks Expert Group & healthdata.be
DCM::RevisionDate 05-01-2016
DCM::Superseeds
DCM::Version 0.0.1

Revision History

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.

Information model

Be.en.hd.GlasgowComaScaleModel.png
Refer to the legend page for more information about the used types and data types

rootconcept GlasgowComaScale
Definition Root concept of the GlasgowComaScale building block. This root concept contains all data elements of the GlasgowComaScale building block.
Type Zib.png
data GlasgowComaScaleDateTime
Definition Time at which the EMV score was determined.
Datatype TS.png
data ExplanationEScore
Definition 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.
Datatype ST.png
data ExplanationMScore
Definition Reason why no motor response test could be done. This is to be entered as free text.
Datatype ST.png
DCM::ExampleValue Spierverslappers
data ExplanationVScore
Definition 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.

Datatype ST.png
DCM::ExampleValue Vtube
data TotalScore
Definition 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.
Datatype INT.png
DCM::ExampleValue 10
data Explanation
Definition Comment on (the context of) the EMV score measurement, such as any problems or factors that may influence interpretation.
Datatype ST.png
DCM::ExampleValue Patient was direct voor intubatie volkomen helder; reageert nu minder maar is ook onderkoeld (temperatuur rectaal 35°C).
data GCS_Eyes
Definition 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.
Datatype CO.png
DCM::ExampleValue 3
DCM::ValueSet File:List.png GCS_EyesCodeList OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.1
data GCS_Motor
Definition 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.
Datatype CO.png
DCM::ExampleValue 4
DCM::ValueSet File:List.png GCS_MotorCodeList OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.2
data GCS_Verbal
Definition 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.
Datatype CO.png
DCM::ExampleValue 3
DCM::ValueSet File:List.png GCS_VerbalCodelijst OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.3
DCM::ValueSet File:List.png GCS_VerbalCodelijstBaby OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.5
DCM::ValueSet File:List.png GCS_VerbalCodelijstKleuter OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.4

Code Lists

GCS_EyesCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.12.8.1

Concept Name Value Concept Code Coding Syst. Name Coding System OID Description
Spontaneous 4 E4 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 3 E3 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 pati\'ebnt]
To pain only 2 E2 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 1 E1 GCS_Eyes 2.16.840.1.113883.2.4.3.11.60.40.4.2.1 Geen reactie [De ogen blijven gesloten]

GCS_MotorCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.12.8.2

Concept Name Value Concept Code Coding Syst. Name Coding System OID Description
Obeys 6 M6 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 5 M5 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 4 M4 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 3 M3 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 2 M2 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 1 M1 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

OID:2.16.840.1.113883.2.4.3.11.60.40.2.12.8.3

Concept Name Value Concept Code Coding Syst. Name Coding System OID Description
Oriented 5 V5 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Geori\'ebnteerd [Helder en duidelijk bewust van de situatie]
Confused 4 V4 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 3 V3 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 2 V2 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 1 V1 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Geen reactie [Geen enkel verbale response]

GCS_VerbalCodeListToddler

OID:2.16.840.1.113883.2.4.3.11.60.40.2.12.8.4

Concept Name Value Concept Code Coding Syst. Name Coding System OID Description
Oriented 5 V5 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 4 V4 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Onjuiste woorden [Verwarde woorden]
Inappropriate speech 3 V3 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Huilen [Aanhoudend huilen of krijsen]
Incomprehensible sounds 2 V2 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Kreunen [Alleen kreunen]
No response 1 V1 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Geen reactie [Geen enkel verbale response]

GCS_VerbalCodeListBaby

OID:2.16.840.1.113883.2.4.3.11.60.40.2.12.8.5

Concept Name Value Concept Code Coding Syst. Name Coding System OID Description
Oriented 5 V5 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Lachen en huilen [Lacht of huilt zachtjes]
Confused 4 V4 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Huilen [Huilt en is onpasselijk]
Inappropriate speech 3 V3 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 2 V2 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Kreunen [Kreunen en onrustig/rusteloos]
No response 1 V1 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Geen reactie [Geen enkel verbale response]

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].