Title Page

  • Conducted on

  • Prepared by

  • Location

Patient's location and info

  • patient file number

  • Age

  • weight(Kg)

  • Height(cm)

  • Gender

  • Which department?

  • Under which unit?

  • Under which unit?

  • Under which unit?

  • Under which unit?

Availability of the form in the patient's file

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

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

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

  • 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?

  • 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):

  • 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?

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

  • Creatinine level and weight is documented?

BOX 1 to be filled by nurses

  • Is the patient demographics completely filled?

Risk assessment

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

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

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

Prophylaxis options

  • Which option did the doctor choose?

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

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

  • 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?

  • 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):

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

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

  • 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):

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

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

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

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

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

  • what is the name and dose of the drug?

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

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

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

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

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

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

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

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

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

  • Was the form signed by the doctor?

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