How to Accurately Assess GCS (By Component) 

General Principles (Before You Start) 
Assess Eye → Verbal → Motor, in that order. 
Use the least stimulus necessary first. 
Score what the patient does, not what you think they can do. 
If something can’t be assessed (e.g. intubated), document why (e.g. “V = intubated”). 
Record each component separately, not just the total. 
 
1. Eye Opening (E) – Best eye response observed 
 
4 – Spontaneous 
Observe on approach 
Eyes open without stimulation 
3 – To speech 
Call patient’s name 
Opens eyes to voice 
2 – To pain 
Apply central pain 
Opens eyes only to pain 
1 – None 
Pain applied 
No eye opening 
 
Key Tips 
Speak clearly before using pain. 
Central pain preferred (trapezius squeeze or supraorbital pressure). 
Do not count eye opening caused by reflex blinking. 
 
2. Verbal Response (V) – Best verbal response

5 – Oriented 
Ask person/place/time 
“I’m John, in hospital, it’s Monday” 
4 – Confused 
Converses but disoriented 
Wrong date or place 
3 – Inappropriate words 
Speech without conversation 
Random or shouted words 
2 – Incomprehensible sounds 
Moaning or groaning 
No recognizable words 
1 – None 
Pain applied 
No verbal response 
 
Key Tips 
Ask open questions (“Can you tell me where you are?”). 
Don’t prompt or correct the patient. 
If intubated → document “V = (intubated)”, not “1”. 
 
3. Motor Response (M) – Most important predictor of outcome 
 
6 – Obeys commands 
Ask simple action 
“Lift your arm” 
5 – Localizes pain 
Apply central pain 
Purposeful movement to pain 
4 – Withdraws from pain 
Central pain 
Pulls away but not purposeful 
3 – Abnormal flexion 
Pain applied 
Decorticate posture 
2 – Extension 
Pain applied 
Decerebrate posture 
1 – None 
Pain applied 
No movement 
 
Key Tips 
Always check command-following first. 
Use central pain to differentiate localization vs withdrawal. 
Score the best response seen. 
If asymmetric, document both sides (e.g. R>L)
Escalate immediately if one sided weakness noted

Pain Stimulus: Best Practice 
Recommended 
Trapezius squeeze 
Supraorbital pressure 
Avoid 
Sternal rub (causes bruising) 
Nail bed pressure (can give false withdrawal) 
 
Documenting GCS Correctly 
 
Correct format: 
GCS 13 = E3 V4 M6 at 14:30 
If not testable: 
GCS = E4 V Nt(intubated) M6 
 
Never write: 
 
“Patient drowsy” 
“Low GCS” 
Just a number without components 
 
Common Errors (Exam + Clinical) 
 
Guessing verbal score in intubated patients 
Using peripheral pain only 
Scoring reflex movement as localization 
Forgetting that motor score matters most 
Failing to compare with previous GCS (trend!) 
 
Key Point: 
 
A falling GCS is an emergency — even a 1–2 point drop is significant and must be escalated.