Authors

  1. Hansen, Bonnie BSN, RN, TNS
  2. Quick, Jacque BSA, RN, TNS
  3. Sinkovits, Eva MS, RN, TNS
  4. Smith, June C. MSN, RN, TNS

Abstract

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.