Venous thromboembolism (VTE) screening must be clearly documented and guide prophylaxis.
The following information and recommendations are being shared to assist facilities in their continuous quality improvement.
The Non-Hospital Medical and Surgical Facilities Patient Safety Incident Review Panel has reviewed incidents of VTE where:
- screening was not apparent or clearly documented in the clinical chart
- VTE risk assessments were scored incorrectly
- interventions or lack thereof where not documented
VTE events can seriously and negatively impact patients in the short and long term.
VTE risk stratification using a standardized tool such as the Caprini risk assessment model should be used. Interventions should be determined based on score. If an intervention is recommended and not done this must be documented.
Facility staff and physicians working in facilities are reminded that a patient’s pre-admission assessment must include appropriate VTE screening, and documentation of the VTE screening must provide an accurate account of the patient’s status including any decisions, interventions or actions taken as a result of this screening.
The screening form used, including score, must be clearly documented in the patient record. See the NHMSFAP Pre-admission Evaluation and Selection and the Medical Records and Documentation accreditation standards for further details.