Chart Audit Form VTE Prophylaxis

Chart Audit Form Specs (see companion page, next Chart Audit Form page) VTE Prophylaxis Institution: Emory Format: Paper Scope: all inpatients Pages: one (with data entry on front, VTE audit assessment printed on back) Content /Use: data collection Hospital Date Audited: / / personnel fills this out while looking at chart (active (HDA) DD/MM/YY patient on floor or discharged patient with chart in medical records); use of digits makes this a ‘self-coding’ form capable of being scanned into a database; the last Date of Admission Orders: ___/___/___ ____:_____ item is key but other information on form often useful DD/MM/YY 24 hr clock Hospital Patient MR# __________ Nursing Unit ________________ Age __________ Admitting Physician __________________________ Weight __________ kg / lbs signer of admission orders Creatinine __________ Responsible Physician __________________________ signer of progress note on HDA VTE RISK LEVEL (for HDA: auditor uses decision support on reverse) ___________ 01 low risk 03 very high risk 02 intermediate-to-high risk ADMISSION ORDER SET W/ VTE RISK ASSESSMENT USED 11 no ___________ 12 yes STPROPHYLAXIS ORDERED WITHIN 1 24 HRS OF ADMISSION ___________ 21 none 22 mechanical 23 pharmacologic 24 both mechanical and pharmacologic ACTIVE PROPHYLAXIS ORDER ON HOSPITAL DATE ...