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)
Yes    No

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.

Non Pharmacologic
___ 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.)
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

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
Myeloproliferative disorder
Congestive heart failure
Active malignancy
Hormonal replacement
Moderate to major surgery

Prior history of VTE
Impaired mobility
Inflammatory bowel disease
Active rheumatic disease
Sickle cell disease
Estrogen-based contraceptives
Central venous catheter

Acute or chronic lung disease
Known thrombophilic state
Varicose veins/chronic stasis
Recent post-partum with
Nephrotic syndrome
Myocardial infarction


Contraindications or Other Conditions to Consider With Pharmacologic VTE Prophylaxis

Absolute Relative Other Conditions
  • Active hemorrhage.
  • Severe trauma to head or spinal cord with hemorrhage in the last 4 weeks.
  • Other___________________
  • Intracranial hemorrhage within last year.
  • Craniotomy within 2 weeks
  • Intraocular surgery within 2 weeks.
  • Gastrointestinal, genitourinary hemorrhage within the last month.
  • Thrombocytopenia (<50K) or coagulopathy (prothrombin time >18 seconds).
  • End stage liver disease.
  • Active intracranial lesions/neoplasms.
  • Hypertensive urgency/emergency.
  • Post-operative bleeding concerns**
  • Immune mediated heparin-induced thrombocytopenia.
  • Epidural analgesia with spinal catheter (current or planned).

** 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 last reviewed October 2014
Page originally created August 2008
Internet Citation: Appendix D. Chart Audit Form. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.