Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | GCSEyeHi | 3465 | GCS Eye Opening High | 1989-10-01 - Variable Added |
Form 1 | GCSEyeLo | 3466 | GCS Eye Opening Low | 1989-10-01 - Variable Added |
Form 1 | GCSMotHi | 3467 | GCS Motor High | 1989-10-01 - Variable Added |
Form 1 | GCSMotLo | 3468 | GCS Motor Low | 1989-10-01 - Variable Added |
Form 1 | GCSTotHi | 3469 | GCS Total ED High | 1989-10-01 - Variable Added |
Form 1 | GCSTotLo | 3470 | GCS Total ED Low | 1989-10-01 - Variable Added |
Form 1 | GCSVerHi | 3471 | GCS Verbal High | 1989-10-01 - Variable Added |
Form 1 | GCSVerLo | 3472 | GCS Verbal Low | 1989-10-01 - Variable Added |
SEVERITY - ARCHIVE
GCS (GLASGOW COMA SCALE) - ARCHIVE
Definition
Glasgow Coma Scale while subject is in care of the Emergency Medical Service.
- On admission to Model System emergency department
- Highest score recorded in the 24 hours following *first EMS contact
- Lowest score recorded in the 24 hours following *first EMS contact
Form
[X] Form 1
[ ] Form 2
Source
- Form 1 - Abstraction (acute record)
Details
Highest and lowest GCS scores should be recorded for all three responses (eyes, verbal, and motor) at once.
Highest and Lowest scores recorded in the 24 hours following first EMS contact include the Model System EMS and ED admission scores if recorded.
If only 1 GCS is recorded, use that score for all three assessments. If patient is in barbiturate coma or paralyzed by use of Pavalin at the time of assessment, record individual items as 7 and total as 77. The coma or paralysis must be induced by medical personnel and not by patient.
Only code “chemically induced coma” with neuromuscular blocking agents or barbiturates.
If patient is intubated at the time of assessment, record the verbal score as 8 and the total score as 88. For the purposes of analysis, these cases will not be included unless specified for recoding during analysis.
If patient is intubated and in chemically-induced coma or paralysis, code 8 for verbal response and 7’s for eye opening, motor response and total GCS.
Utilize the highest and lowest motor score on the GCS as a guide for determining the highest and lowest GCS scores recorded in the 24 hours following *first EMS contact.
GCS scores recorded when the patient is chemically paralyzed should not be included as the highest or lowest GCS scores.
GCS scores recorded when the patient is intubated can be included as the highest or lowest GCS scores by using the motor score or the Becker conversion score .
Reference
Teasdale G, Jennett B (1976) Assessment and Prognosis of Coma After Head Injury, Acta Neurochir 34, 45-55.
Variables
Codes and Values
ID 3465
For Form: [Form 1]
For Variables: [GCSEyeHi]
Code | Description |
|---|---|
1 | None |
2 | To Pain |
3 | To Voice |
4 | Spontaneous |
7 | Patient Chemically Paralyzed ( Or in chemically-induced coma for treatment purposes;*sedated ) |
9 | Unknown Eye Opening Response |
ID 3466
For Form: [Form 1]
For Variables: [GCSEyeLo]
Code | Description |
|---|---|
1 | None |
2 | To Pain |
3 | To Voice |
4 | Spontaneous |
7 | Patient Chemically Paralyzed ( Or in chemically-induced coma for treatment purposes;*sedated ) |
9 | Unknown Eye Opening Response |
ID 3467
For Form: [Form 1]
For Variables: [GCSMotHi]
Code | Description |
|---|---|
1 | None |
2 | Extension to Pain |
3 | Flexion to Pain |
4 | Withdraws from Pain |
5 | Localizes Pain |
6 | Obeys Commands |
7 | Patient Chemically Paralyzed ( Or in chemically-induced coma for treatment purposes;*sedated ) |
9 | Unknown Motor Response |
ID 3468
For Form: [Form 1]
For Variables: [GCSMotLo]
Code | Description |
|---|---|
1 | None |
2 | Extension to Pain |
3 | Flexion to Pain |
4 | Withdraws from Pain |
5 | Localizes Pain |
6 | Obeys Commands |
7 | Patient Chemically Paralyzed ( Or in chemically-induced coma for treatment purposes;*sedated ) |
9 | Unknown Motor Response |
ID 3469
For Form: [Form 1]
For Variables: [GCSTotHi]
Code | Description |
|---|---|
77 | Patient Chemically Paralyzed ( Or in chemically-induced coma for treatment purposes;*sedated ) |
88 | Patient Intubated at time of Scoring |
99 | Unknown Total GCS Score |
ID 3470
For Form: [Form 1]
For Variables: [GCSTotLo]
Code | Description |
|---|---|
77 | Patient Chemically Paralyzed ( Or in chemically-induced coma for treatment purposes;*sedated ) |
88 | Patient Intubated at time of Scoring |
99 | Unknown Total GCS Score |
ID 3471
For Form: [Form 1]
For Variables: [GCSVerHi]
Code | Description |
|---|---|
1 | None |
2 | Incomprehensible Sounds |
3 | Inappropriate Speech |
4 | Confused |
5 | Oriented |
7 | Patient Chemically Paralyzed ( Or in chemically-induced coma for treatment purposes;*sedated ) |
8 | Patient Intubated at time of Scoring |
9 | Unknown Verbal Response |
ID 3472
For Form: [Form 1]
For Variables: [GCSVerLo]
Code | Description |
|---|---|
1 | None |
2 | Incomprehensible Sounds |
3 | Inappropriate Speech |
4 | Confused |
5 | Oriented |
7 | Patient Chemically Paralyzed ( Or in chemically-induced coma for treatment purposes;*sedated ) |
8 | Patient Intubated at time of Scoring |
9 | Unknown Verbal Response |
History
Date | Description |
|---|---|
1994-02-01 | Added NOTE : to clarify which GCS scores to use. |
1995-01-01 | Dropped 88 and 8=Not applicable codes. |
1995-07-01 | Added NOTE : highest/lowest now collected within 24 hours of injury; this includes EMS and initial ED score. |
1995-07-01 | Added CODES : 7 for individual items and 77 for total = chemically induced coma or paralysis. Added |
1996-04-01 | Changed CODES : for patient intubated from "T" and "TT" to "8" and "88". |
1999-04-01 | Added NOTE : regarding determining highest and lowest GCS scores when patient is chemically paralyzed and/or intubated. |
1999-07-01 | Added NOTE : revised definition for highest and lowest scores to be within 24 hours following first EMS contact. |
1999-10-01 | Added NOTE : which stated for highest and lowest score can use model system EMS and ED GCS. |
2003-01-01 | Deleted NOTE : “highest score” and “lowest score” for all GCS variables and all related instructions. |
PUPILLARY RESPONSE - ARCHIVE
Definition
This variable describes pupillary response to light stimulation at time of the initial neurological evaluation following injury (System Admission) and the worst results during the first 24 hrs. after injury.
Form
[X] Form 1
[ ] Form 2
Source
- Abstraction (acute record)
Details
Document left (OS) and right (OD) pupils separately. Worst scores for each eye may be from different exams during the first 24-hour period after injury.
Worst score within the first 24 hours post-injury can include Model System ED, but not any EMS data.
If only one reading is available within the first 24 hours post injury, use it as the initial and worst score.
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | PupilInitL | 3505 | Pupillary Response - Initial Eye Left | 1989-10-01 - Variable Added |
Form 1 | PupilInitR | 3506 | Pupillary Response - Initial Eye Right | 1989-10-01 - Variable Added |
Form 1 | PupilWorstL | 3507 | Pupillary Response - Worst Eye Left | 1989-10-01 - Variable Added |
Form 1 | PupilWorstR | 3508 | Pupillary Response - Worst Eye Right | 1989-10-01 - Variable Added |
Codes and Values
ID 3505
For Form: [Form 1]
For Variables: [PupilInitL]
Code | Description |
|---|---|
1 | Brisk or Normal Reaction (BR) + |
2 | Sluggish Reaction (SR) + |
3 | No Reaction (NR) |
7 | Not Applicable: Closed by swelling |
8 | Not Applicable: Eye absent or blind |
9 | Unknown ( Or eye sutured closed ) |
ID 3506
For Form: [Form 1]
For Variables: [PupilInitR]
Code | Description |
|---|---|
1 | Brisk or Normal Reaction (BR) + |
2 | Sluggish Reaction (SR) + |
3 | No Reaction (NR) |
7 | Not Applicable: Closed by swelling |
8 | Not Applicable: Eye absent or blind |
9 | Unknown ( Or eye sutured closed ) |
ID 3507
For Form: [Form 1]
For Variables: [PupilWorstL]
Code | Description |
|---|---|
1 | Brisk or Normal Reaction (BR) + |
2 | Sluggish Reaction (SR) + |
3 | No Reaction (NR) |
7 | Not Applicable: Closed by swelling |
8 | Not Applicable: Eye absent or blind |
9 | Unknown ( Or eye sutured closed ) |
ID 3508
For Form: [Form 1]
For Variables: [PupilWorstR]
Code | Description |
|---|---|
1 | Brisk or Normal Reaction (BR) + |
2 | Sluggish Reaction (SR) + |
3 | No Reaction (NR) |
7 | Not Applicable: Closed by swelling |
8 | Not Applicable: Eye absent or blind |
9 | Unknown ( Or eye sutured closed ) |
History
Date | Description |
|---|---|
1999-04-01 | Changed CODE : to unknown code "(or eye suture closed)" |
2001-10-01 | Changed CODE : "4 - Closed by swelling" to "7 - Closed by swelling" to avoid misinterpretation of "4" as a scale score. |
2002-01-01 | Changed CODE : added "N/A" to code "7" and code "8" to further clarify that it is not in the hierarchy. |
RANCHO - ARCHIVE
Definition
Rancho Los Amigos Scale is completed at the following times: a)Within 72 hours following admission to inpatient rehabilitation, and b) Discharge from inpatient rehabilitation.
Form
[X] Form 1
[ ] Form 2
Source
- Abstraction (rehab record)
Details
If Rancho Level assessment is not completed within the 72 hour windows, they should still reflect the patients’ status within that time period. If this is not possible and the assessments are done out of the 72 hour window, use code 9. Every effort should be made to obtain the Rancho level, however, if not assessed, use code 9. Do not leave blanks.
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | RanchoA | 3513 | Rancho Los Amigo Scale Rehab Admission | 1989-10-01 - Variable Added |
Form 1 | RanchoD | 3514 | Rancho Los Amigo Scale Rehab Discharge | 1989-10-01 - Variable Added |
Codes and Values
ID 3513
For Form: [Form 1]
For Variables: [RanchoA]
Code | Description |
|---|---|
1 | Level I No Response ( Patient does not respond to external stimuli and appears asleep ) |
2 | Level II Generalized Response ( Patient reacts to external stimuli in nonspecific, inconsistent, and nonpurposeful manner with stereotypic and limited responses ) |
3 | Level III Localized Response ( Patient responds specifically and inconsistently with delays to stimuli, but may follow simple commands for motor action ) |
4 | Level IV Confused, Agitated Response ( Patient exhibits bizarre, nonpurposeful, incoherent or inappropriate behaviors, has no short term recall, attention is short and nonselective ) |
5 | Level V Confused, Inappropriate, Nonagitated Response ( Patient gives random, fragmented, and nonpurposeful responses to complex or unstructured stimuli. Simple commands are followed consistently, memory and selective attention are impaired, and new information is not retained. ) |
6 | Level VI Confused, Appropriate Response ( Patient gives context appropriate, goal directed responses, dependent upon external input for direction. There is carry over for relearned, but not for new tasks, and recent memory problems persist ) |
7 | Level VII Automatic, Appropriate Response ( Patient behaves appropriately in familiar settings, performs daily routines automatically, and shows carry over for new learning at lower than normal rates. Patient initiates social interactions, but judgment remains impaired. ) |
8 | Level VIII Purposeful, Appropriate Response ( Patient orients and responds to the environment, but abstract reasoning abilities are decreased relative to premorbid levels ) |
9 | Unknown ( Or assessment done outside of 72 hour window ) |
ID 3514
For Form: [Form 1]
For Variables: [RanchoD]
Code | Description |
|---|---|
1 | Level I No Response ( Patient does not respond to external stimuli and appears asleep ) |
2 | Level II Generalized Response ( Patient reacts to external stimuli in nonspecific, inconsistent, and nonpurposeful manner with stereotypic and limited responses ) |
3 | Level III Localized Response ( Patient responds specifically and inconsistently with delays to stimuli, but may follow simple commands for motor action ) |
4 | Level IV Confused, Agitated Response ( Patient exhibits bizarre, nonpurposeful, incoherent or inappropriate behaviors, has no short term recall, attention is short and nonselective ) |
5 | Level V Confused, Inappropriate, Nonagitated Response ( Patient gives random, fragmented, and nonpurposeful responses to complex or unstructured stimuli. Simple commands are followed consistently, memory and selective attention are impaired, and new information is not retained. ) |
6 | Level VI Confused, Appropriate Response ( Patient gives context appropriate, goal directed responses, dependent upon external input for direction. There is carry over for relearned, but not for new tasks, and recent memory problems persist ) |
7 | Level VII Automatic, Appropriate Response ( Patient behaves appropriately in familiar settings, performs daily routines automatically, and shows carry over for new learning at lower than normal rates. Patient initiates social interactions, but judgment remains impaired. ) |
8 | Level VIII Purposeful, Appropriate Response ( Patient orients and responds to the environment, but abstract reasoning abilities are decreased relative to premorbid levels ) |
9 | Unknown ( Or assessment done outside of 72 hour window ) |
History
Date | Description |
|---|---|
1994-02-01 | Deleted NOTE : references to Level I data collection and Acute discharge assessment. |
1994-02-01 | Deleted CODES : Dates of assessment and "88 - N/A" code. |
1994-09-13 | Added CODE : "99 - Unknown". |
1999-10-01 | Changed CODE : "99 - Unknown" to "9 - Unknown". |
RTS - ARCHIVE
Definition
Revised Trauma Score while subject is in care of Emergency Medical Service.
Respiratory Rate – code actual rate per minute (use 3 characters)
Systolic Blood Pressure – code actual blood pressure (use 3 characters)
Form
[X] Form 1
[ ] Form 2
Source
*Form 1 - Abstraction (acute record)
Details
Computer will calculate Revised Trauma Score from these data and the EMS GCS.
If patient was brought to the hospital by some method other than EMS, code 999 for Systolic Blood Pressure and Respiratory Rate.
If data is available from more than one EMS, use first available EMS data.
If a range rather than a single score is given for Respiratory Rate or Systolic Blood Pressure, enter the RAW SCORE that (a) produces the worst code, using the coding equivalents below, and (b) is closest to the midpoint of the range. (“Worst code”= numerically lowest code.) See the EXAMPLE.
If respiratory rate is between 10 and 29, Respiratory Score=4. If respiratory rate is 30 or above, Respiratory Score=3. If respiratory rate is between 6 and 9, Respiratory Score=2. If respiratory rate is between 1 and 5, Respiratory Score=l. If respiratory rate is 0, Respiratory Score=0. If systolic blood pressure is 90 or above, Systolic Blood Pressure Score=4. If systolic blood pressure is between 76 and 89, Systolic Blood Pressure Score=3. If systolic blood pressure is between 50 and 75, Systolic Blood Pressure Score=2. If systolic blood pressure is between 1 and 49, Systolic Blood Pressure Score= 1. If systolic blood pressure is 0, Systolic Blood Pressure Score=0.
EXAMPLE:
Scoring when a single rate (rather than range of rates) is provided:
At admission to ED, patient had a respiratory rate of 30/minute and a systolic blood pressure of 80mmHg. a. Respiratory rate 030 c. Systolic blood pressure 080
Determining a single rate when a range of rates is provided:
At admission to ED, patient had a respiratory rate of between 8 and 12 per minute.
First step: Determine which scores within the range produce the worst code. a. Use the respiratory rate coding equivalences (in NOTES) to determine the code equivalences for the scores within with range. -> Within the range 8-12, the scores 8 and 9 equal code “2” (see line 3 of the coding equivalences) -> Within the range 8-12, the scores 10, 11, and 12 equal code “4” (see line 1 of the coding equivalences) b. Determine which of these codes is the worst code. -> “2” is lower than “4”, so “2” is the worst code. c. Identify the score or scores that equal the worst code. -> Scores 8 and 9 equal “2”, the worst code. (If only one score equals the worst code, enter that score. Do the additional steps below only if more than one score equals the worst code.) Second step: Having determined which scores equal the worst code, identify which one of these scores is closest to the midpoint of the range. Enter that score into the database. a. Identify the midpoint of the range. -> The range is 8-12, which includes 8,9,10,11,12. The midpoint score (the middle score) is 10. b. Identify which of the scores that equal the worst code is nearest to the midpoint. -> 8 and 9 equal the worst code. 9 is closer to 10 (the midpoint) than is 8. c. Enter “9” into the database
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | RTSEMSBP | 3527 | ED Revised Trauma Score - Systolic Blood Pressure | 1989-10-01 - Variable Added |
Form 1 | RTSEMSRep | 3528 | ED Revised Trauma Score - Respiratory Rate | 1989-10-01 - Variable Added |
Codes and Values
ID 3527
For Form: [Form 1]
For Variables: [RTSEMSBP]
Code | Description |
|---|---|
888 | Unmeasurable |
999 | Unknown or No EMS |
ID 3528
For Form: [Form 1]
For Variables: [RTSEMSRep]
Code | Description |
|---|---|
888 | Unmeasurable: Bagged |
999 | Unknown or No EMS |
History
No history found for the Domain.