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.