Appendix D. Chart Audit Form
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)
Adequate Prophylaxis Regimens for Each Level of VTE Risk
|Low Risk||Moderate Risk||High risk|
|Early ambulation.||Heparin 5,000 units SC q 8 h or
Heparin 7,500 units SC q 12 h or
Dalteparin 5,000 units SC daily or
Enoxaparin 40 mg SC daily or
Heparin 5,000 units SC q 12 hours
(only for patients with weight <50 kg or age >75 years)
and Suggest adding SCDs
|Dalteparin 5,000 units SC daily or
Enoxaparin 30 mg SC q 12 hours or
Enoxaparin 40 mg SC q day or
Fondaparinux 2.5 mg SC daily or
Warfarin, INR 2-3.
and SCDs (unless not feasible)
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.
___ Sequential compression device Are these in place and on?______
___ Elastic stockings
___ 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.)
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?
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
|Low Risk||Moderate Risk||High risk|
|Ambulatory patient without additional VTE risk factors or expected length of stay <2 days
Minor surgery in patient without additional VTE risk factors (same day surgery or operating room time <30 minutes).
|Patients who aren't in either the low- or high-risk group (go to the VTE risk factor table below)||Elective hip or knee arthroplasty
Acute spinal cord injury with paresis
Multiple major trauma
Abdominal or pelvic surgery for cancer
Venous Thromboembolism Risk Factors
Age >50 years
|Prior history of VTE
Inflammatory bowel disease
Active rheumatic disease
Sickle cell disease
Central venous catheter
Acute or chronic lung disease
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.
Page originally created August 2008