Documenting coma

Coma is defined as “unarousable unresponsiveness.” Patients in a coma are unable to open their eyes, obey commands, or respond to verbal or tactile stimuli as expected. According to Centre for Neuroskills, 90 percent of patient with a Glasgow Coma Scale (GCS) of 8 or less is typically comatose.

The coma diagnosis is often overlooked by providers when documenting, especially in critical care areas. When patients have a low GCS and are found to have some of the following patient characteristics or descriptors in the chart, queries are sent to the provider, questioning any pertinent diagnoses being monitored, evaluated, or treated during the admission.

Patient characteristics/descriptors:

  • Obtunded
  • Does not follow commands
  • Unresponsive to all but deep pain
  • Decorticate or decerebrate posturing
  • May be intubated to protect their airway
  • Consider for patients who are compassionately extubated

Documentation needs:

  • Providers should consider documenting the coma diagnosis, when their patients are comatose.
  • Include the underlying cause of coma (i.e., trauma, diabetic, hepatic, myxedema).
  • Pharmacologic coma, pentobarbital coma, and propofol coma are medically induced comas, and since these are therapies, they are assigned a procedure code in ICD10.
  • The term “unconsciousness” is also classified as coma when a patient is in a persistent (not transient) state of altered level of consciousness.
  • Be cautious when using terms interchangeably. Terms such as “obtunded” or “unresponsive” are not synonymous with coma.
  • Consider whether the condition was present on admission.

More information

Please contact the Clinical Documentation Improvement Department with any questions. Further education regarding this topic is available for your team through the CDI department.

Contact: Deanna Brennan, manager/director, Clinical Documentation Improvement, deanna-brennan@uiowa.edu, 319-353-7033

References

Pinson, R.D., & Tang, C.L. (2016). Reproduced from 2017 CDI Pocket Guide (7th ed.). © 2012 HCPro, Ind., 75 Sylvan Street, Danvers, MA 01923. 781/639-1872. hcpro.com. Used with permission.

Centre for Neurological Skills Website; Neurology Channel.com. NINDS.NIH.gov; Dictionary of Measurement, ed. Russ Rowlett. University of North Carolina at Chapel Hill website.

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