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    41 Glasgow Coma Scale Form

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    Aina Haravata
    This document is a revision record and form for assessing and documenting a patient's Glasgow Coma Scale (GCS). It was established by the Nursing Standards Department and includes sections for patient information, GCS assessment criteria, total score, pupil size and referral criteria. The form was prepared by Kristoffer Nemis, reviewed by Danny Tuazon and Elizabeth Evangelista, and is to be used to standardize GCS documentation.

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    41 Glasgow Coma Scale Form

    Uploaded by

    Aina Haravata
    34 views2 pages
    This document is a revision record and form for assessing and documenting a patient's Glasgow Coma Scale (GCS). It was established by the Nursing Standards Department and includes sections for patient information, GCS assessment criteria, total score, pupil size and referral criteria. The form was prepared by Kristoffer Nemis, reviewed by Danny Tuazon and Elizabeth Evangelista, and is to be used to standardize GCS documentation.

    Original Description:

    Original Title

    41 GLASGOW COMA SCALE FORM

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    This document is a revision record and form for assessing and documenting a patient's Glasgow Coma Scale (GCS). It was established by the Nursing Standards Department and includes sections for patient information, GCS assessment criteria, total score, pupil size and referral criteria. The form was prepared by Kristoffer Nemis, reviewed by Danny Tuazon and Elizabeth Evangelista, and is to be used to standardize GCS documentation.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    34 views2 pages

    41 Glasgow Coma Scale Form

    Uploaded by

    Aina Haravata
    This document is a revision record and form for assessing and documenting a patient's Glasgow Coma Scale (GCS). It was established by the Nursing Standards Department and includes sections for patient information, GCS assessment criteria, total score, pupil size and referral criteria. The form was prepared by Kristoffer Nemis, reviewed by Danny Tuazon and Elizabeth Evangelista, and is to be used to standardize GCS documentation.

    Copyright:

    © All Rights Reserved
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    of 2

    Form No.

    : BWH-NSD-04-041
    Revision No.: 00
    Revision Date: 00-00-00

    REVISION HISTORY

    Document No.: BWH-NSD-04-041 Document Title: Glasglow Coma Scale Form

    DCN EFFECTIVE REVISION REVISION


    DESCRIPTION OF REVISION PAGE AFFECTED ORIGINATOR
    NUMBER DATE NUMBER TYPE

    Newly established form in Kristoffer C. Nemis,


    00 N/A N/A
    accordance to Nursing standards RN MAN

    PREPARATION SECTION
    Section Prepared Reviewed Approved

    NSD Kristoffer C. Nemis, RN MAN Danny Tuazon, MD Elizabeth Evangelista, MD


    Consultant, Nursing Service Founder Head - Nursing Medical Director
    REVIEW OF RELATED DEPT./SECTION

    Dept./Section Reviewed Dept./Section Reviewed

    NSD n/a n/a


    Norfreda Cruz, RN MAN
    Admin n/a n/a
    Charles Cruz, MD
    n/a n/a n/a n/a

    n/a n/a n/a n/a

    n/a n/a n/a n/a

    This is a computer generated form. No STAMPING needed.


    Form No.: BWH-NSD-04-041
    Case No.: 00
    Revision Date: 00-00-00
    GLASGOW COMA SCALE FORM
    PATIENT’S NAME: AGE: SEX: ROOM NO.:
    ATTENDING PHYSICIAN: HOSPITAL NO.:

    Date
    Time

    EYE OPENING
    None 1
    To Pain 2
    Name Called 3
    Spontaneous 4

    MOTOR MOVEMENT
    None 1
    Decerebrate 2
    Decorticate 3
    Withdraws 4
    Localizes Pain 5
    Follows Command 6

    VERBAL
    None 1
    Grunts 2
    Inappropriate 3
    Disorented 4
    Oriented 5

    TOTAL
    NOD

    PUPIL SIZE (in mm)


    BTRL
    SRTL
    NRTL

    BTRL - brisky reactive to Light SRTL - sluggishly reactive to light NRTL - not reactive to light

    When to refer ASAP

    1. Pupils not equals in size 3. Patient complaining severe 5. Patient’s GCS score decreasing 2
    2. Pupils dilating (5mm in size) headache, vomiting points from baseline
    4. Patient’s sensorium is decreasing 6. Seizure
    7. GCS 6 and below

    Nurse Name/ License No./ Signature Duty Date/ Time Nurse Name/License No./ Signature Duty Date/Time

    1._ 4._

    2._ 5._

    3._ 6._

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