DVT prophylaxis risk assessment

• Conducted on

  Date

• Prepared by

• Location
  Address

Patient's location and info

• patient file number

• Age

• weight(Kg)

• Height(cm)

• Gender

  Male

  Female

• Which department?

  Select Medical Surgical Orthopedics ICU HDU Urology Plastic

  • Medical
  • Surgical
  • Orthopedics
  • ICU
  • HDU
  • Urology
  • Plastic

• Under which unit?

  Select medical A1 medical A2 medical B1 medical B2 medical C1 medical C2 medical D1 medical D2 medical E1 medical E2 cardiology Nephrology Surgical A Surgical B Surgical C Surgical D Urology Orthopedics Plastic Other + Add Response

  • medical A1
  • medical A2
  • medical B1
  • medical B2
  • medical C1
  • medical C2
  • medical D1
  • medical D2
  • medical E1
  • medical E2
  • cardiology
  • Nephrology
  • Surgical A
  • Surgical B
  • Surgical C
  • Surgical D
  • Urology
  • Orthopedics
  • Plastic
  • Other
  • + Add Response

• Under which unit?

  Select medical A1 medical A2 medical B1 medical B2 medical C1 medical C2 medical D1 medical D2 medical E1 medical E2 cardiology Nephrology Surgical A Surgical B Surgical C Surgical D Urology Orthopedics Plastic Other + Add Response

  • medical A1
  • medical A2
  • medical B1
  • medical B2
  • medical C1
  • medical C2
  • medical D1
  • medical D2
  • medical E1
  • medical E2
  • cardiology
  • Nephrology
  • Surgical A
  • Surgical B
  • Surgical C
  • Surgical D
  • Urology
  • Orthopedics
  • Plastic
  • Other
  • + Add Response

• Under which unit?

  A

  B

  C

  D

• Under which unit?

  Select MEDICAL A1 MEDICAL A2 MEDICAL B1 MEDICAL B2 MEDICAL C1 MEDICAL C2 MEDICAL D1 MEDICAL D2 MEDICAL E1 MEDICAL E2 NEPHROLOGY CARDIOLOGY

  • MEDICAL A1
  • MEDICAL A2
  • MEDICAL B1
  • MEDICAL B2
  • MEDICAL C1
  • MEDICAL C2
  • MEDICAL D1
  • MEDICAL D2
  • MEDICAL E1
  • MEDICAL E2
  • NEPHROLOGY
  • CARDIOLOGY

Availability of the form in the patient's file

• Is the form available in the patient's file?

  Yes

  No

• Is there any orders of prophylaxis(pharmacological or mechanical) written in the patient's file or in the medication list?

  Yes

  No

• If the answer is Yes, what type of prophylaxis was ordered?

  Select Enoxaparin 0.4 ml s.c every 24 hrs Enoxaparin 0.2 ml s.c every 24 hrs Enoxaparin 0.4 ml s.c every 12 hrs other drugs/doses mechanical compression unfractionated heparin(Minihep)

  • Enoxaparin 0.4 ml s.c every 24 hrs
  • Enoxaparin 0.2 ml s.c every 24 hrs
  • Enoxaparin 0.4 ml s.c every 12 hrs
  • other drugs/doses
  • mechanical compression
  • unfractionated heparin(Minihep)

• if you choose (other drug/doses), write the name and dose

• If There was an order for prophylaxis(pharmacological or mechanical) in the file, was it started within 24 hrs of admission or surgery?

  Yes

  No

• If There is NO order for prophylaxis(pharmacological or mechanical) in the file or in the medication list, choose one of the following mobility status of the patient(You can get this info from the assigned nurse and by confirming with the patient and his family):

  Bedfast – Confined to bed.

  Chairfast – Ability to walk is severely limited or nonexistent. Cannot bear own weight and/or must be assisted into a chair or wheelchair.

  Walks occasionally – Walks occasionally during the day, but only for very short distances, with or without assistance. Spends the majority of each shift in bed or in a chair.

  Walks frequently – Walks outside of the room at least twice a day and inside the room at least once every 2 hours during waking hours.

• if the form is available in the patient's file, continue with following sections

BOX 2 to be filled by nurses

• Is the time and date of admission documented?

  Yes

  No

• Is the time of start of prophylaxis documented(whether its is mechanical or pharmacological)?

  Yes

  No

• Creatinine level and weight is documented?

  Yes

  No

BOX 1 to be filled by nurses

• Is the patient demographics completely filled?

  Yes

  No

Risk assessment

• For the medical department's form, are some of the boxes checked for mobility and risk factors of thrombosis?

  Yes

  No

• For the Surgical department's form, are some of the boxes checked for risk factors of thrombosis?

  Yes

  No

• For the Surgical department's form, did the doctor write the total score?

  Yes

  No

Prophylaxis options

• Which option did the doctor choose?

  Select Enoxaparin 0.4 ml s.c every 24 hrs Enoxaparin 0.2 ml s.c every 24 hrs Enoxaparin 0.4 ml s.c every 12 hrs other drugs/doses mechanical compression No Prophylaxis Nothing was chosen

  • Enoxaparin 0.4 ml s.c every 24 hrs
  • Enoxaparin 0.2 ml s.c every 24 hrs
  • Enoxaparin 0.4 ml s.c every 12 hrs
  • other drugs/doses
  • mechanical compression
  • No Prophylaxis
  • Nothing was chosen

• Is there any orders of prophylaxis(pharmacological or mechanical) written in the patient's file or in the medication list?

  Yes

  No

• If the answer is Yes, what type of prophylaxis was ordered?

  Select Enoxaparin 0.4 ml s.c every 24 hrs Enoxaparin 0.2 ml s.c every 24 hrs Enoxaparin 0.4 ml s.c every 12 hrs other drugs/doses mechanical compression unfractionated heparin(Minihep)

  • Enoxaparin 0.4 ml s.c every 24 hrs
  • Enoxaparin 0.2 ml s.c every 24 hrs
  • Enoxaparin 0.4 ml s.c every 12 hrs
  • other drugs/doses
  • mechanical compression
  • unfractionated heparin(Minihep)

• if you choose (other drug/doses), write the name and dose

• If There was an order for prophylaxis(pharmacological or mechanical) in the file, was it started within 24 hrs of admission or surgery?

  Yes

  No

• If There is NO order for prophylaxis(pharmacological or mechanical) in the file or in the medication list, choose one of the following mobility status of the patient(You can get this info from the assigned nurse and by confirming with the patient and his family):

  Bedfast – Confined to bed.

  Chairfast – Ability to walk is severely limited or nonexistent. Cannot bear own weight and/or must be assisted into a chair or wheelchair.

  Walks occasionally – Walks occasionally during the day, but only for very short distances, with or without assistance. Spends the majority of each shift in bed or in a chair.

  Walks frequently – Walks outside of the room at least twice a day and inside the room at least once every 2 hours during waking hours.

• Did the doctor tick one of the reasons listed for why (No prophylaxis) was chosen?

  Yes

  No

• If the answer is Yes, What was the reason for choosing (No prophylaxis)?

  Low risk for DVT

  Contraindication of both anticoagulant and mechanical prophylaxis

  Others

• If the option (low-risk for DVT) was chosen, choose one of the following mobility status of the patient(You can get this info from the assigned nurse and by confirming with the patient and his family):

  Bedfast – Confined to bed.

  Chairfast – Ability to walk is severely limited or nonexistent. Cannot bear own weight and/or must be assisted into a chair or wheelchair.

  Walks occasionally – Walks occasionally during the day, but only for very short distances, with or without assistance. Spends the majority of each shift in bed or in a chair.

  Walks frequently – Walks outside of the room at least twice a day and inside the room at least once every 2 hours during waking hours.

• If the option (Others) was chosen, please write it

• was the mechanical prophylaxis applied within 24 hrs of admission or surgery?

  Yes

  No

• Did the doctor tick one of the reasons listed for why they choose mechanical prophylaxis?

  Yes

  No

• if the answer is Yes, What was the reason for choosing mechanical prophylaxis?

  Active bleeding

  High risk of thrombosis (require both mechanical and anticoagulant prophylaxis)

  Others

• if the answer is Yes, did the doctor filled the risk factors of bleeding(found in the back of the page) ?

  Yes

  No

• what is the name and dose of the drug?

• was it given within 24 hrs of admission or surgery?

  Yes

  No

• was it given within 24 hrs of admission or surgery?

  Yes

  No

• is the weight of the patient more than 100 kg?

  Yes

  No

• was it given within 24 hrs of admission or surgery?

  Yes

  No

• is the weight of the patient less than 40 kg?

  Yes

  No

• is the creatinine clearance less than 30? (calculate clearance by using cockroft-Gault formula)

  Yes

  No

• was it given within 24 hrs of admission or surgery?

  Yes

  No

• is the weight of the patient between 40-100 kg?

  Yes

  No

• is the creatinine clearance more than 30? (calculate clearance by using cockroft-Gault formula)

  Yes

  No

• Was the form signed by the doctor?

  Yes

  No