VTE Screening K-Card

HAC SPS Bundle Elements

Which department are you completing this survey for?

Name of the employee observed:

Patient MRN?

Was the patient screened for risk of VTE on admission, daily, and/or change in patient condition?

All patients 12 years or older should be screened.
When screening for VTE were the VTE risk factors considered?

VTE Risk Factors Include:

a. Mobility status- Baseline or Altered (Braden QD: Mobility 1-2)
b. Personal history of thrombosis
c. Thrombophilia
d. Critically Ill (in the ICU)
e. Active cancer/malignancy
f. Recent surgery within the past 30 days
g. Estrogen Therapy currently taking or within the past 2 weeks
h. Acute Systemic Inflammation or Infection
i. Trauma
j. Obesity
k. Burns (>50-65% total BSA)
l. Severe Dehydration
m. Protein Losing Disorder
n. Cyanotic Heart Disease or low flow states
o. Family History of VTE from a 1st degree relative
Comments

If No is chosen, please provide more details.