Coma scale, eyes open, spontaneous, EMR

This code indicates a patient's neurological status upon arrival at the emergency department, specifically documenting that their eyes were spontaneously open. It is a component of the Glasgow Coma Scale (GCS) assessment, reflecting the highest level of eye-opening response. This finding suggests a relatively preserved level of consciousness compared to other eye-opening responses.

This code is appropriate when the patient's initial GCS assessment in the emergency department reveals spontaneous eye-opening. Documentation should clearly state "eyes open spontaneously" or a GCS eye-opening score of 4, specifically recorded at the time of ED arrival. It is used for patients presenting with altered mental status due to various etiologies, such as trauma, stroke, or overdose.

• Ensure the documentation explicitly states "at arrival to emergency department" for this specific GCS component.
• Do not use this code if eye-opening required verbal or painful stimuli; separate codes exist for those responses.
• Always code all three components of the GCS (eye, verbal, motor) when documented, along with the underlying condition causing the altered mental status.