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

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

---

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 Dehydration 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 Obesity Known thrombophilic state Varicose veins/chronic stasis Recent post-partum with immobility 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.

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