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DVT Prophylaxis Orders for Surgery

This document contains a thrombosis risk factor assessment form for elective general surgery patients. It lists various patient risk factors and assigns point values from 1 to 5 points depending on the risk level of the factor. The form is to be used to determine a total risk factor score for each patient by selecting all applicable risk factors and adding up the subtotals from each risk factor category. The total score will help assess the patient's risk of developing deep vein thrombosis and determine appropriate prophylaxis orders.

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Loy Zi
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297 views1 page

DVT Prophylaxis Orders for Surgery

This document contains a thrombosis risk factor assessment form for elective general surgery patients. It lists various patient risk factors and assigns point values from 1 to 5 points depending on the risk level of the factor. The form is to be used to determine a total risk factor score for each patient by selecting all applicable risk factors and adding up the subtotals from each risk factor category. The total score will help assess the patient's risk of developing deep vein thrombosis and determine appropriate prophylaxis orders.

Uploaded by

Loy Zi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd

SOMERIAN ASSESSMENT AND PRIMARY HEALTH CARE CENTER

Musaffah, Abu Dhabi, United Arab Emirates

Deep Vein Thrombosis (DVT) Prophylaxis Orders


(For use in Elective General Surgery Patiens)

Thrombosis Risk Factor Assessment


(Choose all that apply)

MRN: ____________
PATIENT
PATIENT NAME :______________________________________ DATE: _____/____/_____ DMY IDENTIFICATION
ROOM: ______________
BIRTHDAY: ___/___/___/ DMY AGE: ______ NATIONALITY: ___________
DOCTOR NAME: ______________________________________GENDER: MALE FEMALE
DIAGNOSIS :____________________________________________________________________

Each Risk Factor Represents 1 Point Each Risk Factor Represents 2 Points

Age 41-60 years Acute Myocardial Infarction Age 61-74 years Cental venous access
Swollen legs (current) Congestive Heart Failure (<1 month) Arthroscopic surgery Major surgery (>45 mins)
Varicose veins Abnormal pulmonary function ( Malignancy (present or previous)
Obesity (BMI >25) Medical patient currently at bed res Laparoscopic surgery (>45 mins)
Minor surgery planned History of inflammatory bowel diseas Patient confined to bed (>72 hours)
Sepsis (<1 month) History of inflammatory bowel dise Immobilizing plaster cast (<1month)
Serious lung disease including pneumonia (1<month) Subtotal:
Oral contraceptives or hormone replacement therapy
Pregnancy or postpartum (1<month)
History of unexplained stillborn infant, recurrent spontaneous
abortion(>3), premature birth with toxemia or growth-restricte Each Risk Factor Represents 3 Points
Other risk factors ______________ Age 75 years o older Family history of thrombosis
Subtotal: History of DVT/PE Positive Prothrombin 20210A
Positive Factor V Leiden Positive Lupus Anticoagulant
Elevated serum homocysteine
Heparin-induced thrombocytopenia (HIT)
Each Risk Factor Represents 5 Points (Do not use heparin or any low molecular weight heparin)
Stroke (<1 month) Multiple Trauma (<1 month) Elevated anticardiolipin antibodies
Elective major lower extremity arthroplasty Other congenital or acquired trombophilia
Hip, pelvis or leg fracture (<1 month) If yes: Type ______________________
Acute spinal cord injury (paralysis) (<1 month) *most frequently missed risk factor
Subtotal: Subtotal:

TOTAL RISK FACTOR SCORE:

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