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DVT Assessment Form

This document appears to be an order form for Deep Vein Thrombosis (DVT) prophylaxis for elective general surgery patients from a health care center in Abu Dhabi. It includes a thrombosis risk factor assessment where doctors can select from various risk factors that apply to each patient and assign them point values depending on the risk level. The risk factors are totaled to determine an overall risk factor score to help assess each patient's DVT risk and determine appropriate prophylaxis orders.

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Loy Zi
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2K views1 page

DVT Assessment Form

This document appears to be an order form for Deep Vein Thrombosis (DVT) prophylaxis for elective general surgery patients from a health care center in Abu Dhabi. It includes a thrombosis risk factor assessment where doctors can select from various risk factors that apply to each patient and assign them point values depending on the risk level. The risk factors are totaled to determine an overall risk factor score to help assess each patient's DVT risk 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 PDF, TXT or read online on Scribd
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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
DATE: _____/____/_____ DMY
PATIENT NAME :__________________________________________ IDENTIFICATION
BIRTHDAY: ___/___/___/
ROOM: ______________ 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 (COPD) Malignancy (present or previous)
Obesity (BMI >25) Medical patient currently at bed rest Laparoscopic surgery (>45 mins)
Minor surgery planned History of inflammatory bowel disease Patient confined to bed (>72 hours)
Sepsis (<1 month) History of inflammatory bowel disease 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-restricted infant 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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