VTE risk assessment and prophylaxis data collection form. V3
Date?Fortnight ending FridayPatient group Medical Orthopaedic Surgical (non-ortho) Post-partum Pregnant in-patient Other Guidelines used NICE Padua Caprini ACCP Local Other Patient reference number?At risk of VTE? Low risk At risk (/High risk) Medium risk Bleeding risk? No Yes Not assessed as not applicable Contraindication to stockings?No Yes Not assessed as not applicable Renal impairment (GFR below threshold for dose reduction in your guidelines) Normal Renal impairment Not known Weight?Normal (50-100 kg) Low (weight under 50 kg) High (over 100 kg) Not known The appropriate thromboprophylaxis for this patient should be LMWH/Heparin ___________________Drug Dose FrequencyNo LMWH/Heparin No mechanical compression Compression stockings Intermittent compression device Foot pump LMWH/Heparin prescription at 24 hours post-admission None Tinzaparin 4500 Tinzaparin 3500 Tinzaparin 2500 Enoxaparin 40 Enoxaparin 20 Heparin 5000 bd Tinzaparin greater than 4500 Enoxaparin greater than 40 Other LMWH/Heparin administered by 24 hours post-admission Yes No (not administered) Not applicable (patient not on LMWH/heparin) Mechanical compression prescription at 24 hours None Foot pump Compression stockings Intermittent compression device Other Mechanical compression in place at 24 hours None Foot pump Compression stockings Intermittent compression device Other LMWH / heparin appropriatenessAppropriate: Indicated, not C/I, Rx correct Not indicated, no Rx C/I, not prescribed Under-prophylaxis: Indicated, not prescribed Over-prophylaxis: Not indicated, prescribed Risk of bleeding: Prescribed but C/I Wrong dose for weight Wrong dose for renal function Mechanical compression appropriatenessAppropriately:Indicated, in place Not indicated, not in place C/I, not in place Inappropriately:Under-prophylaxis: Indicated, not in place Over-prophylaxis: Not indicated, in place Inappropriate: C/I but in place Wrong size Risk assessment form filledNo form Yes –completed No – available but not completed Evidence of risk assessment Yes – form completed Yes – other evidence No Not assessed Comments ?Note: Shaded sections are required fields for data entry to Excel spreadsheet ................
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