Today much of our knowledge about a patient's level of consciousness is given to us by his or her score on the Glasgow Coma Scale (GCS). Since its development at the University of Glasgow in 1974, it has been widely adopted, become an integral component of the hourly "neuro assessment", and is typically incorporated into the graphic assessment portion of the patient's medical record. Once the information has been documented, the pure data itself is lost as the documented form takes on an interpretative meaning or a reality that is different from the clinical state experienced by the patient. The formation of this "new" reality occurs in two separate phases: in the completion of the scale and in its reading. There are various factors or forces that affect the completion and use of the scale. These are important as they are not visible in the scale itself; however, their effects are evident in the coma score obtained. These forces include the design of the GCS and the manner in which the tool is taught and used. The purpose of this paper is to discuss these factors and to delineate how they create a reality that may not accurately depict the patient's level of consciousness.
