June 25, 2024

We have a patient who is legally blind and has two fake eyes. We have documentation in the chart stating spontaneous eye movement and a total GCS of 15 within the first 30 mins of arrival. How should we answer the question for GCS eye? If the patient were to have a head injury, what would we answer for pupillary response?

Great questions! For GCS-Eye Opening, the assessment is of the stimulus to induce eye opening, not the vision itself. As stated, you have documentation of GCS 15 and that would be appropriate to capture. For Pupillary Response you would record neither reactive. This aligns with the guidance in the NTDS Data Dictionary that states, “Field value 2. One reactive should be reported for patients who have a prosthetic eye.” Since the patient has two prosthetic eyes, you would record neither reactive.

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