Coma scale, eyes open, to pain, EMR

This code indicates a patient's eye-opening response to pain upon arrival at the emergency department, as assessed using the Glasgow Coma Scale (GCS). It signifies a specific level of neurological impairment where the patient's eyes open only in response to a painful stimulus. This finding is crucial for evaluating the severity of acute brain injury or altered mental status.

Apply this code when documentation clearly states a GCS eye-opening score of 2, specifically noting "eyes open to pain" or "painful stimulus required for eye opening," recorded upon the patient's initial presentation to the ED. This is typically used for patients presenting with head trauma, stroke, overdose, or other conditions affecting consciousness.

• Always confirm the GCS score and the specific component (eye opening) from the ED physician's or nurse's initial assessment documentation.
• Do not confuse this with other GCS eye-opening scores (e.g., spontaneous, to speech, no response).
• Sequence this code after the primary diagnosis indicating the reason for the altered mental status or brain injury.