How Is TBI Documented?
When the patient is brought to the emergency room for examination, a patient’s degree of consciousness is often used to determine the severity of his/her brain injury. Instruments such as the Glasgow Coma Scale (GCS) use the patient’s ocular, motor, and verbal responsiveness to measure level of consciousness. Scores of 8 or below are considered to represent a true coma (no eye opening, no response to simple commands, and unable to communicate) and to indicate a severe brain injury. Scores from 9 – 12 are suggestive of a moderate brain injury. GCS scores of 13 and above are thought to indicate that the brain injury is mild. The duration of coma (LOC) is also used to measure severity of injury and to predict outcome. The longer the LOC, the more severe the brain injury. LOC greater than 6 hours postadmission is considered to be a severe brain injury. LOC between 20 minutes and 6 hours postadmission is considered to be moderate brain injury. LOC of less than 20 minutes is considered to be
