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==Revision History==
 
==Revision History==
 
<div class="mw-collapsible mw-collapsed">
 
<div class="mw-collapsible mw-collapsed">
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''Only available in Dutch<!--noTranslation-->''
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<u>Publicatieversie 1.0</u> (15-02-2013)
 
<u>Publicatieversie 1.0</u> (15-02-2013)
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<u>Publicatieversie 3.0</u> (01-05-2016)
 
<u>Publicatieversie 3.0</u> (01-05-2016)
 
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This information model is also available as [[Media:nl.zorg.GlasgowComaScale-v3.1(2019EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.GlasgowComaScale-v3.1(2019EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]<!--ftDownloads-->
 
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==About this information<!--ftHeader2-->==
 
==About this information<!--ftHeader2-->==
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The information in this wikipage is based on<!--ftInfoBase--> Prerelease 2019-1 <BR>
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The information in this wikipage is based on<!--ftInfoBase--> Prerelease 2019-2 <BR>
 
SNOMED CT and LOINC codes are based on:
 
SNOMED CT and LOINC codes are based on:
 
<ul>
 
<ul>
−
<li>SNOMED Clinical Terms version: 20190131 [R] (January 2019 Release)</li>
+
<li>SNOMED Clinical Terms version: 20190731 [R] (July 2019 Release)</li>
 
<li>LOINC version 2.64</li>
 
<li>LOINC version 2.64</li>
 
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Huidige versie van 4 feb 2020 om 00:47


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: 2019
Release status: Prepublished
Release date: 31-01-2020

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 31-01-2020
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 31-12-2017
DCM::Supersedes 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)

ZIB-453 Wijziging naamgeving ZIB's en logo's door andere opzet van beheer

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 VerbalCodelistBaby#GCS VerbalCodelistToddler#9347#9345#9346#GCS VerbalCodelist#9352#GCS MotorCodelist#GCS EyesCodelist#9350#9348#9344#12771#ConditionsDuringMeasurementCodelistGlasgowComaScale-v3.1Model(2019EN).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 Score motor response subscore
List2.png GCS_MotorCodelist
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_VerbalCodelist
List2.png GCS_VerbalCodelistBaby
List2.png GCS_VerbalCodelistToddler
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.
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

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

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: 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_MotorCodelist

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_VerbalCodelist

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_VerbalCodelistBaby

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_VerbalCodelistToddler

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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Information model references

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Technical specifications in HL7v3 CDA and HL7 FHIR

To exchange information based on health and care information models, additional, more technical specifications are required.
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 Prerelease 2019-2
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms version: 20190731 [R] (July 2019 Release)
  • LOINC version 2.64

Conditions for use are located on the mainpage List2.png
This page is generated on 03/02/2020 01:38:47 with ZibExtraction v. 4.0.7338.2051

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