Documentation and Scores

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Medical documentation is important for communication among
health care professionals, for research, legal defense, and
reimbursement. Neurological scoring systems are used to assess
the severity of illness in patients with neurological emergencies,
and can be used to monitor the clinical course, to document
complications of therapy and to help identify prognostic factors.
Two types of scoring systems are commonly used: neurological
scoring systems, to quantify neurological deficits, like the
Glasgow Coma Scale or the Mini-Mental Status Examination; and
functional scoring systems to characterize patients’ abilities to
perform activities of daily living, used to quantify the functional
outcome with or without therapy, like the Canadian Neurological
Score, the NIH stroke scale, the modified Rankin scale, the
expanded disability status scale, the Richmond agitation
sedation score and the confusion assessment method.
Neurological scoring is used in the critical care unit while scores
for activities of daily living are used for the outcome assessment.
Intensive care units (ICUs) provide a service for patients with
potentially recoverable diseases who can benefit from more
detailed observation and treatment than is usually available on
the general wards. Patients may be discharged from the ICU
when their physiologic status has stabilized and the need for ICU

monitoring and care is no longer necessary (Egol 1999).
However, a number of patients who are successfully discharged
from intensive care subsequently die during their hospital
admissions. This may indicate premature discharge from the ICU
or suboptimal management in the ICU or the general ward
(Campbell 2008). As trends move towards earlier ICU discharge,
it becomes increasingly important to be able to identify those
patients at high risk of subsequent clinical deterioration, who
might benefit from longer ICU stays or from transfers to
intermediate care units. A strategy to reduce premature
discharges in patients at high risk of in-hospital death could
result in a 39% reduction in post-ICU death in these patients
(Daly 2001). It can be concluded that reliable baseline and followup
assessment is crucial to document any improvement or
deterioration in neurological status of patients admitted to a
neurocritical care unit. Interrater differences may be significant,
so the need for standardized neurological scales and scores
comes into play.
Scales seek to quantify different aspects of function within the
framework of the World Health Organization hierarchy of
impairment, disability, and handicap (Thuriaux 1995). Since the
introduction of the Mathew scale in 1972 (Mathew 1972), there
has been a steadily increasing number of scales that seek to
quantify neurological impairment. These scales involve scoring
different modalities of neurological function and then sum the
scores to provide an index for neurological status. These scales
were developed for a variety of reasons, including monitoring
neurological status for improvement or deterioration (Cote 1986)
and predicting final outcome in a defined group of patients
(Brott 1989). The primary purpose for these scales in
neurocritical care units is to compare the baseline neurological
impairment severity of patients at admission, and to quantify
neurological recovery over time, to avoid premature discharge
from the neurocritical care unit and promote early detection of
deterioration and prompt management.

Scoring and Documentation
Each neurocritical care unit should adopt a special scoring and
documentation system, to be used to assess and document
baseline patient neurological status and status at time of
discharge. These include:
– Vital Signs: BP, temp, pulse, respiration, oximetry
– Pupils: size and reaction to light
– Eye movement: gaze, vergence, individual extraocular
movement and nystagmus
– Mental status: LOC, orientation and speech
– Motor functions: state, power, tone, deep reflexes and
pathological reflexes
– Coordination: gate, upper and lower limbs, if applicable
There are many scales used to assess these functions; each
critical care unit can adopt a set that can be used by its staff.
Tables 3.1, 3.2, and 3.3 show some of the commonly used scales
in clinical practice.

Table 3.1 – Neurological Scales used for assessment of level of
consciousness and mental status
Name and Source Strengths and Weaknesses
Level-of-consciousness scale
Glasgow Coma Scale
(Teasdale 1974, 1979)
Strength: Simple, valid, reliable, for assessment of
level-of-consciousness.
Weaknesses: none observed.
Full Outline
Unresponsiveness – FOUR
Score
(Wijdicks 2005)
Strength: The FOUR score is easy to apply and
provides more neurological details than the
Glasgow scale. This scale is able to detect
conditions such locked-in syndrome and the
vegetative state, which are not detected by the
GCS.
Weaknesses: none observed.
Delirium Scale
Confusion Assessment
Method (CAM)
(Inouye 1990)
Strength: CAM-ICU is an adaptation of the
Confusion Assessment Method (CAM), which was
adapted to be a delirium assessment tool for use in
ICU patients (e.g., critically ill patients on and off
the ventilator who are largely unable to talk).
Weaknesses: none observed.
Richmond Agitation
Sedation Scale (RASS)
(Sessler 2002)
Strength: RASS is logical, easy to administer, and
readily recalled. RASS has high reliability and
validity in medical and surgical, ventilated and
non-ventilated, and sedated and non-sedated
adult ICU patients.
Weaknesses: none observed
Mental status screening
Folstein Mini-Mental State
Examination (Folstein 1975)
Strength: Widely used for screening.
Weaknesses: Several functions with summed
score. May mis-classify patients with aphasia.
Neurobehavioral Cognition
Status Exam (NCSE)
(Kiernan 1987)
Strength: Predicts gain in Barthel Index scores.
Unrelated to age.
Weaknesses: Does not distinguish right from left
hemisphere. No reliability studies in stroke. No
studies of factorial structure. Correlates with
education.

Table 3.2 – Neurological Scales used for assessment of stroke deficits
Name and Source Strengths Weaknesses
Measures of disability/activities of daily living (ADL)
Barthel Index
(Mahoney 1965,
Wade 1988)
Widely used for stroke.
Excellent validity and
reliability.
Low sensitivity for high-level
functioning
Functional
Independence
Measure (FIM)
(Granger 1987)
Widely used for stroke.
Measures mobility, ADL,
cognition, functional
communication.
"Ceiling" and "floor" effects
Stroke deficit scales
NIH Stroke Scale
(Brott 1989)
Brief, reliable, can be
administered by nonneurologists
Low sensitivity
Canadian
Neurological Scale
(Cote 1986)
Brief, valid, reliable Some useful measures omitted
Assessment of motor function
Fugl-Meyer
(Fugl-Meyer 1975)
Extensively evaluated
measure. Good validity
and reliability for
assessing sensorimotor
function and balance
Considered too complex and timeconsuming
by many
Motor Assessment
Scale (Poole 1988)
Good, brief assessment of
movement and physical
mobility
Reliability assessed only in stable
patients. Sensitivity not tested
Motricity Index
(Collin 1990)
Brief assessment of motor
function of arm, leg, and
trunk
Sensitivity not tested
Balance assessment
Berg Balance
Assessment
(Berg 1992)
Simple, well established
with stroke patients,
sensitive to change
None observed
Mobility assessment
Rivermead
Mobility Index
(Collen 1991)
Valid, brief, reliable test of
physical mobility
Sensitivity not tested

Name and Source Strengths Weaknesses
Assessment of speech and language functions
Boston Diagnostic
Aphasia
Examination
(Goodglass 1983)
Widely used,
comprehensive, good
standardization data,
sound theoretical
rationale
Long time to administer; half of
patients cannot be classified
Porch Index of
Communicative
Ability (PICA)
(Porch 1981)
Widely used,
comprehensive, careful
test development and
standardization
Long time to administer. Special
training required to administer.
Inadequate sampling of language
other than one word and single
sentences
Western aphasia
Battery (Kertesz
1982)
Widely used,
comprehensive
Long time to administer. "Aphasia
quotients" and "taxonomy" of
aphasia not well validated
Table 3.3 – Neurological Scales used for assessment of health status and
global disabilities
Type Name and
Source
Strengths Weaknesses
Global
disability scale
Rankin Scale
(Rankin 1957,
Bonita 1988,
Van Swieten
1988)
Good for overall
assessment of
disability.
Walking is the only
explicit assessment
criterion. Low
sensitivity
Health status/
quality of life
measures
Medical
Outcomes Study
(MOS) 36 Item
Short-Form
Health Survey
(Ware 1992)
Generic health status
scale SF36 is improved
version of SF20. Brief,
can be self -
administered or
administered by phone
or interview. Widely
used in the US
Possible "floor" effect
in seriously ill patients
(especially for physical
functioning), suggests it
should be
supplemented by an
ADL scale in stroke
patients
Sickness Impact
Profile (SIP)
(Bergner 1981)
Comprehensive and
well-evaluated. Broad
range of items reduces
"floor" or "ceiling"
effects
Time to administer
somewhat long.
Evaluates behavior
rather than subjective
health; needs questions
on well-being,
happiness, and
satisfaction

Delirium
Delirium is a disturbance of consciousness characterized by
acute onset and fluctuating course of inattention accompanied
by either a change in cognition or a perceptual disturbance, so
that a patient’s ability to receive, process, store, and recall
information is impaired.
Delirium, a medical emergency, develops rapidly over a short
period of time, is usually reversible, and is a direct consequence
of a medical condition or a brain insult. Many delirious ICU
patients have recently been comatose, indicating a fluctuation of
mental status. Comatose patients often, but not always, progress
through a period of delirium before recovering to their baseline
mental status.
ICU delirium is a predictor of increased mortality, length of
stay, time on ventilator, costs, re-intubation, long-term cognitive
impairment, and discharge to long-term care facility; it
necessitates special attention, assessment and management.
Delirium assessment is actually an important part of the overall
assessment of consciousness.
Delirium includes three subtypes: hyperactive, hypoactive and
mixed. Hyperactive delirium is characterized by agitation,
restlessness, and attempts to remove tubes and lines. Hypoactive
delirium is characterized by withdrawal, flat affect, apathy,
lethargy, and decreased responsiveness. Mixed delirium is
characterized by fluctuation between the hypoactive and
hyperactive. In ICU patients mixed and hypoactive are the most
common, and are often undiagnosed if routine monitoring is not
implemented. Few ICU patients (less than 5%) experience purely
hyperactive delirium.
The Confusion Assessment Method (CAM) was created in 1990
by Sharon Inouye, and was intended to be a bedside assessment
tool usable by non-psychiatrists to assess for delirium (Inouye
1990). The CAM-ICU is an adaptation of this tool for use in ICU
patients (e.g., critically ill patients on and off the ventilator who
are largely unable to talk).