FOUR Score (Full Outline of UnResponsiveness)
Assesses comatose patients with greater neurological detail than GCS, including brainstem reflexes and respiration
- Highest activation tier
- Recommended
- How it is scored
- Scored in code; a detected disagreeing draft value is flagged for correction
- Care settings
- ICU
When it activates
Scribeable activates a calculator from the encounter. The FOUR Score (Full Outline of UnResponsiveness) can activate when the transcript or pasted chart context documents any of these:
- Coma assessment in intubated patient
- Detailed neurological assessment in obtunded patient
- Brainstem function evaluation
- ICU neurological monitoring
- Prognostication in comatose patient
A coded diagnosis can also activate it. ICD-10 prefixes carried by the registry: R40, S06.
Note-type scope: it activates on notes whose subject resolves to neurology, critical care, emergency medicine. A note that resolves to another subject does not carry it even when the clinician's specialty matches; a note with no resolvable subject (a generic consultation) falls back to the specialty match.
Inputs the note needs
4 inputs. Each is resolved from the transcript, the pasted chart context and charted labs; at this calculator’s tier a missing input is never requested, and a missing required input keeps the score out of the draft.
| Input | Type | Unit / options | Guidance |
|---|---|---|---|
| Eye response (0=no opening, 1=opens to pain, 2=opens to loud voice, 3=tracking/blinking on command, 4=opens voluntarily/tracks) | exam | ||
| Motor response (0=no response/myoclonus status, 1=extension, 2=flexion, 3=localizing pain, 4=thumbs-up/fist/peace sign) | exam | ||
| Brainstem reflexes (0=absent pupil+corneal+cough, 1=pupil and corneal absent, 2=pupil or corneal absent, 3=one pupil wide/fixed, 4=all reflexes present) | exam | ||
| Respiration (0=apnea/breathes at ventilator rate, 1=breathes above ventilator rate, 2=not intubated irregular, 3=not intubated Cheyne-Stokes, 4=not intubated regular) | exam |
Scoring
4 components each scored 0-4: Eye + Motor + Brainstem + Respiration. Total range 0-16.
Eye Eye response (0=no opening, 1=opens to pain, 2=opens to loud voice, 3=tracking/blinking on command, 4=opens voluntarily/tracks) + Motor Motor response (0=no response/myoclonus status, 1=extension, 2=flexion, 3=localizing pain, 4=thumbs-up/fist/peace sign) + Brainstem Brainstem reflexes (0=absent pupil+corneal+cough, 1=pupil and corneal absent, 2=pupil or corneal absent, 3=one pupil wide/fixed, 4=all reflexes present) + Respiration Respiration (0=apnea/breathes at ventilator rate, 1=breathes above ventilator rate, 2=not intubated irregular, 3=not intubated Cheyne-Stokes, 4=not intubated regular) (each 0-4)
Interpretation
FOUR 0: Possible brain death — evaluate for brain death testing. FOUR 1-6: Severe impairment, poor prognosis. FOUR 7-12: Moderate impairment. FOUR 13-16: Mild impairment or normal. Advantage over GCS: can assess intubated patients, tests brainstem reflexes, detects locked-in syndrome.
Evidence
Sources carried in Scribeable's citation registry for this calculator; guideline version: Wijdicks EFM et al. 2005.
- Wijdicks EF et al. Validation of a new coma scale: the FOUR scoreWijdicks et al. (FOUR Score) 2005 · 2005 · Mayo Clinic · Level I · link last verified 2026-03-28
How Scribeable handles it in the note
When an encounter activates the FOUR Score (Full Outline of UnResponsiveness) (its highest tier is recommended), Scribeable does not ask you for missing inputs. The score is computed in code from whatever inputs resolve from the transcript, the pasted chart context or charted labs; a computed value is written into the draft only when every required input already resolves.
The score is computed in code from the resolved inputs, not recalled by the language model. If the draft states a FOUR Score (Full Outline of UnResponsiveness) value that disagrees with the computed one, the disagreement is flagged to the second drafting pass, which is instructed to correct the score and its interpretation before you see the note.
Classified as a risk score: activated strictly, by a documented trigger, never by a permissive reading of the encounter.
See it activate on your own encounter
14 days of full Pro. No sales call.
14-day Pro trial with a card on file. $79/month starts 14 days after your trial begins unless you cancel first. Cancel any time from Settings > Billing.