Glasgow coma scale: how to improve and enhance documentation.
The Glasgow Coma Scale (GCS) is an international tool used to measure the level of consciousness for traumatically injured patients. One Level I and 3 Level II Trauma Centers in our Health Care System perceived a deficiency in the documentation of the GCS. An audit was performed and insufficient documentation was confirmed. An educational plan was developed and implemented to improve documentation. A reaudit was performed to determine the success of these interventions. Although improvement was demonstrated, additional action was taken to enhance documentation in the electronic medical record.
Highland Park Hospital (Ms Hansen), Evanston Hospital (Ms Quick), Skokie Hospital (Ms Sinkovits), and Glenbrook Hospital (Ms Smith), NorthShore University HealthSystem, Evanston, Illinois.
Bonnie
B
Hansen
Jacque
J
Quick
Eva
E
Sinkovits
June C
JC
Smith
D004282:Documentation / Q000379:methods*; D057286:Electronic Health Records; D005260:Female; D015600:Glasgow Coma Scale / Q000592:standards*; D006801:Humans; D008297:Male; D020380:Needs Assessment; D009460:Neurologic Examination / Q000379:methods; D011786:Quality Control; D012042:Registries; D012189:Retrospective Studies; D014193:Trauma Centers / Q000458:organization & administration*; D015599:Trauma Severity Indices; D014481:United States; D014947:Wounds and Injuries / Q000175:diagnosis* / Q000628:therapy