Appendix D. Chart Audit Form

Preventing Hospital-Acquired Venous Thromboembolism

Reviewer _____________________ MR# _________________ Name ___________________  Dx#1 _______
Date/Time ___________________    Date of Admission ______________________________   Dx#2 _______
Ht: ____________   Wt ____________   BMI ____________   Age ____________   Sex   M   F       Dx#3 _______
Service ______________________ Ward/Location _______________________________________________

1. Is patient eligible for survey? (i.e., not currently on full anticoagulation)
Yes    No    If No, stop here.

2. Assign venous thromboembolism risk (Refer to VTE risk factors table and circle category).
Low    Moderate    High

3. Does patient have relative or absolute contraindications to pharmacologic prophylaxis or condition of concern? (circle appropriate category, if present)
Yes    No

Adequate Prophylaxis Regimens for Each Level of VTE Risk

This table is to be used only in audit tools; it is not for use in order sets. Sequential compression devices (SCDs) are appropriate if anticoagulant use is contraindicated.

4. Document current prophylaxis ordered.

Non Pharmacologic
___ Sequential compression device    Are these in place and on?______
___ Elastic stockings

Pharmacologic
___ Heparin 5,000 units subcutaneous q 12 hours
___ Heparin 7,500 units subcutaneous q 12 hours
___ Heparin 5,000 units subcutaneous q 8 hours
___ Enoxaparin (Lovenox) 40 mg subcutaneous q day
___ Enoxaparin (Lovenox) 30 mg subcutaneous q 12 hours
___ Dalteparin (Fragmin) 2,500 units subcutaneous q day
___ Dalteparin (Fragmin) 5,000 units subcutaneous daily
___ Fondaparinux (Arixtra) 2.5 mg subcutaneous daily ($28.63/day). Start 6 hours post-op.
___ Coumadin ______mg daily
___ Other ________________________________________________________________________________

5. Do the prophylactic measures match the measures in the above table? (Remember that SCDs alone may be appropriate in patients who have contraindications to pharmacologic prophylaxis.)
Yes    No

6. If mismatch, notify physician within 24 hours.
Physician notified ____________    Date/Time ____________

7. Did physician change order to a matched prophylaxis as a result of the intervention?
Yes    No

8. If no, list reason given below.

9. Final judgment: Was the prophylaxis ordered for the patient at the time of the survey adequate?
Yes    No    Not Sure

Venous Thromboembolism Risk Factors

Contraindications or Other Conditions to Consider With Pharmacologic VTE Prophylaxis

** Scheduled return to OR within the next 24 hours: major ortho: 24 hours leeway; spinal cord or ortho spine: 7 days leeway; general surgery, status post transplant, status post trauma admission: 48 hours leeway.