TEMPLATE NIHSS_UKSH (NIHSS_UKSH)

TEMPLATE IDNIHSS_UKSH
ConceptNIHSS_UKSH
DescriptionDas Template wird verwendet, um die Ergebnisse der National Institutes of Health Stroke Scale (NIHSS) als quantitatives Maß für schlaganfallbedingte neurologische Defizite zu erfassen.
UseDer Gesamtscore, der als quantitatives Maß für schlaganfallbedingte neurologische Defizite dient, ergibt sich aus der Summe der Punkte für die 15 Kriterien (ausgenommen der Kriterien, die nicht getestet werden konnten) und beträgt maximal 42. Je höher der NIHSS-Score ist, desto stärker ausgeprägt sind die neurologischen Defizite des Patienten. Der Wert '99' wird verwendet, um den nicht-numerischen Wert 'nicht testbar' auszudrücken. Derzeit ist eine Kombination aus numerischen und nicht-numerischen Werten innerhalb eines einzigen Wertesatzes nicht möglich.
PurposeDas Template wird verwendet, um die Ergebnisse der National Institutes of Health Stroke Scale (NIHSS) als quantitatives Maß für schlaganfallbedingte neurologische Defizite zu erfassen.
References
Authorsdate: 2025-07-24; name: Carlotta Jöhnk; organisation: Universitätsklinikum Schleswig-Holstein
Other Details Languagedate: 2025-07-24; name: Carlotta Jöhnk; organisation: Universitätsklinikum Schleswig-Holstein
Other Details (Language Independent)
  • Sem Ver: 0.2.1
  • MD5-CAM-1.0.1: e47e5cdc618fa5e0d8882346361059fc
  • PARENT:MD5-CAM-1.0.1: A60D0B7F52F1F9C3C9B3518DB83ACDAE
  • Original Language: ISO_639-1::de
KeywordsSkala, neurologisch, Neurologie, Schlaganfall, Einschätzung, Untersuchung, NIHSS
Language useden
Citeable Identifier1246.169.3935
Root archetype idopenEHR-EHR-COMPOSITION.report.v1
NIHSS_UKSHNIHSS_UKSH: Document to communicate information to others, commonly in response to a request from another party.
Other Context
Report IDReport ID: Identification information about the report.
StatusStatus: The status of the entire report. Note: This is not the status of any of the report components.
Case identificationCase identification: To record case identification details for public health purposes.
Case identifierCase identifier: The identifier of this case.
NIHSSNIHSS: 15-item neurologic examination stroke scale that provides a quantitative measure of stroke-related neurological deficit.
NIHSS - National Institutes of Health Stroke Scale.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
LOC responsivenessLOC responsiveness: Level of Consciousness
  • 0: Alert; keenly responsive. 
  • 1: Not Alert; but arousable by minor stimulation to obey, answer, or respond. 
  • 2: Not Alert; requires repeated stimulation to attend, or is obtunded and requires strong or painful 
  • 3: Responds only with reflex motor or autonomic effects, or totally unresponsive, flaccid, and areflexic. 
LOC questionsLOC questions: Level of Consciousness
  • 0: Answers both questions correctly. 
  • 1: Answers one question correctly. 
  • 2: Answers neither question correctly. 
LOC commandsLOC commands: Level of Consciousness
  • 0: Performs both tasks correctly. 
  • 1: Performs one task correctly. 
  • 2: Performs neither task correctly. 
Best GazeBest Gaze: *
  • 0: Normal. 
  • 1: Partial gaze palsy; gaze is abnormal in one or both eyes, but forced deviation or total gaze paresis is not present. 
  • 2: Forced deviation, or total gaze paresis is not overcome by the oculocephalic maneuver. 
VisualVisual: *
  • 0: No visual loss. 
  • 1: Partial hemianopia. 
  • 2: Complete hemianopia. 
  • 3: Bilateral hemianopia (blind including cortical blindness). 
Facial palsyFacial palsy: *
  • 0: Normal symmetrical movements. 
  • 1: Minor paralysis (flattened nasolabial fold, asymmetry on smiling). 
  • 2: Partial paralysis (total or near-total paralysis of lower face). 
  • 3: Complete paralysis of one or both sides (absence of facial movement in the upper and lower face). 
Motor - left armMotor - left arm: Observation of left arm motor function.
Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as 'Untestable' and record the reason in the 'Reason left arm untestable' data element. Implementation note: Although the 'Untestable' value is included in the ordinal to allow its inclusion in the user interface dropdown menu, NIHSS does not assign a numerical score for the 'Untestable' option in the total NIHSS score.
  • 0: No drift; limb holds 90 (or 45) degrees for full 10 seconds. 
  • 1: Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support. 
  • 2: Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity. 
  • 3: No effort against gravity; limb falls. 
  • 4: No movement. 
  • 99: Untestable: Amputation or joint fusion. 
Reason left arm untestableReason left arm untestable: Amputation or joint fusion, explain:
Motor - right armMotor - right arm: Observation of right arm motor function.
Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as 'Untestable' and record the reason in the 'Reason right arm untestable' data element. Implementation note: Although the 'Untestable' value is included in the ordinal to allow its inclusion in the user interface dropdown menu, NIHSS does not assign a numerical score for the 'Untestable' option in the total NIHSS score.
  • 0: No drift; limb holds 90 (or 45) degrees for full 10 seconds. 
  • 1: Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support. 
  • 2: Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity. 
  • 3: No effort against gravity; limb falls. 
  • 4: No movement. 
  • 99: Untestable: Amputation or joint fusion. 
Reason right arm untestableReason right arm untestable: Amputation or joint fusion, explain:
Motor - left legMotor - left leg: Observation of left leg motor function.
Only in the case of amputation or joint fusion at the hip, the examiner should record the score as 'Untestable' and record the reason in the 'Reason left leg untestable' data element. Implementation note: Although the 'Untestable' value is included in the ordinal to allow its inclusion in the user interface dropdown menu, NIHSS does not assign a numerical score for the 'Untestable' option in the total NIHSS score.
  • 0: No drift; leg holds 30-degree position for full 5 seconds. 
  • 1: Drift; leg falls by the end of the 5-second period but does not hit the bed. 
  • 2: Some effort against gravity; leg falls to bed by 5 seconds but has some effort against gravity. 
  • 3: No effort against gravity; leg falls to bed immediately. 
  • 4: No movement. 
  • 99: Untestable: Amputation or joint fusion. 
Reason left leg untestableReason left leg untestable: Amputation or joint fusion, explain:
Motor - right legMotor - right leg: Observation of right leg motor function.
Only in the case of amputation or joint fusion at the hip, the examiner should record the score as 'Untestable' and record the reason in the 'Reason right leg untestable' data element. Implementation note: Although the 'Untestable' value is included in the ordinal to allow its inclusion in the user interface dropdown menu, NIHSS does not assign a numerical score for the 'Untestable' option in the total NIHSS score.
  • 0: No drift; leg holds 30-degree position for full 5 seconds. 
  • 1: Drift; leg falls by the end of the 5-second period but does not hit the bed. 
  • 2: Some effort against gravity; leg falls to bed by 5 seconds but has some effort against gravity. 
  • 3: No effort against gravity; leg falls to bed immediately. 
  • 4: No movement. 
  • 99: Untestable: Amputation or joint fusion. 
Reason right leg untestableReason right leg untestable: Amputation or joint fusion, explain:
Limb ataxiaLimb ataxia: *
  • 0: Absent 
  • 1: Present in one limb 
  • 2: Present in two limbs 
  • 99: Untestable: Amputation or joint fusion, explain: 
Reason limb ataxia untestableReason limb ataxia untestable: Untestable: Amputation or joint fusion, explain:
SensorySensory: *
  • 0: Normal; no sensory loss. 
  • 1: Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial pain with pinprick, but patient is aware of being touched. 
  • 2: Severe or total sensory loss; patient is not aware of being touched in the face, arm, and leg. 
Best LanguageBest Language: *
  • 0: No aphasia; normal. 
  • 1: Mild-to-moderate aphasia; some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression. Reduction of speech and/or comprehension, however, makes conversation about provided materials difficult or impossible. For example, in conversation about provided materials, examiner can identify picture or naming card content from patient’s response. 
  • 2: Severe aphasia; all communication is through fragmentary expression; great need for inference, questioning, and guessing by the listener. Range of information that can be exchanged is limited; listener carries burden of communication. Examiner cannot identify materials provided from patient response. 
  • 3: Mute, global aphasia; no usable speech or auditory comprehension. 
DysarthriaDysarthria: *
Only if the patient is intubated or has other physical barriers to producing speech, the examiner should record the score as 'Untestable' and record the reason in the 'Reason speech untestable' data element. Implementation note: Although the 'Untestable' value is included in the ordinal to allow its inclusion in the user interface dropdown menu, NIHSS does not assign a numerical score for the 'Untestable' option in the total NIHSS score.
  • 0: Normal 
  • 1: Mild-to-moderate dysarthria; patient slurs at least some words and, at worst, can be understood with some difficulty. 
  • 2: Severe dysarthria; patient’s speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric. 
  • 99: Untestable: Intubated or other physical barrier. 
Reason speech untestableReason speech untestable: Intubated or other physical barrier, explain:
Extinction and inattentionExtinction and inattention: *
  • 0: No abnormality. 
  • 1: Visual, tactile, auditory, spatial, or personal inattention, or extinction to bilateral simultaneous stimulation in one of the sensory modalities. 
  • 2: Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space. 
Total scoreTotal score: The total score is the arithmetic sum of all 15 responses, excluding any untestable responses.
0..42