GCS

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
You have clear and repetitive documentation from neurosurgery of: "he does not open his eyes, does not follow commands, does not localize, pupils non-reactive."



Can you code the GCS based on this or do you need them to state that this information relates to the Glascow Coma Scale? If you would query, what would you say? We have a GCS query it just feels redundant since they have already detailed it out.



Thanks!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

Comments

  • catladyrncatladyrn
    edited March 2016
    Aside from the question of whether the descriptors would suffice, the thing that would concern me about that documentation as you've defined it, with reference to GCS, is that there's no documentation of stimulus applied. You're not supposed to record the GCS without actually trying to wake the patient up, i.e., apply pain stimulus, and I don't see that in your neuro note.

    It seems odd to me (having cared for many neuro patients) that the nurses would not have recorded any GCS on this patient. CC1Q2014 says that nonphysician documentation can be used to determine GCS.

    Renée

    Linda Renée Brown, RN, MA, CCDS, CCS, CDIP
    Director, Clinical Documentation
    Tanner Health System
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited March 2016
    I agree Renee, I only included the part the related to what would be the GCS score.

    He was a 3T on arrival and that is not broken down by EMT at the scene or trauma nurse on arrival. I have heard (and it was included in an ACDIS I-10 webinar last week) that we should only be taking GCS from other providers for the EMT or initial reading. Not later GCS scores, that these should be documented by the provider.

    What are your thoughts on this?

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • katysuegood@gmail.comkatysuegood@gmail.com
    edited March 2016
    Jeff,

    It looks like this:

    The Medical Record contains the following Clinical Indicators.

    Total GCS
    Verbal/motor response
    Relevent Pdx or Comobidities? (head injury, trauma,etc)

    Based on your medical assessment of this patient, can you identify the appropriate indicators related to calculation of a Glascow Coma Score __(At time of admission/current/date/etc)___:
    1. Motor Response
    6. Obeys Commands
    5. Localizes Pain (MCC)
    4. Flexion/withdrawal to painful stimulus (MCC)
    3. Abnormal flexion to painful stimuli (decorticate) (MCC)
    2. Extension to painful stimuli (MCC)
    1. No Response/Does not move (MCC)
    Other/Unspecified
    2. Opening of Eyes
    4. Spontaneous
    3. In response to Voice
    2. In response to pain (MCC)
    1. No Response/does not open eyes (MCC)
    Other/Unspecified
    3. Verbal Response
    5. Oriented
    4. Confused
    3. Inappropriate Words
    2. Incomprehensible Words (MCC)
    1. No Response/Makes no sounds/intubated (MCC)
    Other/Unspecified


    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


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