GLASGOW COMA SCALE RESULT

Date and time: [Date, time]
Patient: [Name or ID, age]
Assessed by: [Name, role]
Reason: [Head injury, reduced consciousness, sedation hold, or routine neuro observations]
Interfering factors: [Breathing tube, sedation or paralysis, eye swelling, hearing loss, language, spinal cord injury, or none]

COMPONENTS
Eye opening, E: [1 to 4 or NT; the response seen, such as opens to sound]
Verbal response, V: [1 to 5, NT, or VT if intubated; the response seen, such as confused]
Best motor response, M: [1 to 6 or NT; the response seen and the arm, such as localising with the right arm]
Stimulus used: [Spoken or shouted request, finger tip pressure, trapezius pinch, or supraorbital pressure]
NT reasons: [Each component not tested and why, or none]

SCORE
Total: [E, V, M and the sum from 3 to 15; no total if any component is NT]
Severity: [Mild, moderate, or severe, for head injury]
Pupils: [Size in mm and reaction to light, left and right]
GCS-P: [Total minus 1 for one unreactive pupil or 2 for both, if used]
Limb movement: [Weakness or difference between sides, by limb]

TREND
Previous assessments: [Times and scores, with components]
Change: [Better, stable, or worse; which component changed and by how much]

ACTIONS
Escalation: [Who was told and when, or none needed]
Investigations: [CT head, glucose, others]
Next assessment: [Interval, such as every 30 minutes until back to 15]

Clinician: [Name, credentials]