Performance Measurement Network

Question: Is the ambulatory patient considered low risk for VTE?

If it is documented that the patient is ambulatory within the specified time frame is this considered Low Risk For VTE? And can the abstractor select "yes" to Reason for No VTE Prophylaxis – Hospital Admission?

In the Data Dictionary under Inclusions it lists:

Inclusion Guidelines for Abstraction: Reasons for not administering any mechanical or pharmacologic prophylaxis: • Patient at low risk for VTE • Explicit documentation that the patient does not need VTE prophylaxis

How does the abstractor determine if the patient is at Low Risk? Must there be a Risk Assessment form on the chart that indicates this?

If the physician/PA/APN documents the reason for no VTE prophylaxis is because the patient is ambulatory would this be considered Explicit documentation that the patient does not need VTE prophylaxis?

Answer:

Reason for No VTE Prophylaxis - Hospital Admission is a shared data element with VTE-1. VTE-1 includes all hospitalized medical and surgical patients (500+ codes). Some hospitalized patients are "low risk" for VTE. If the hospital uses a Risk Assessment Form and the nurse completes the assessment within the 2 day timeframe clearly documenting that the patient is at low risk for VTE and does not need VTE prophylaxis, then this is accepatable for this data element.

However, stroke patients are considered to be at higher risk than other medical patients (per clinical practice guidelines). GCS alone are not acceptable for stroke patients because they are at higher risk. If a Risk Assessment Form is completed as described above, you may select "Yes" for Reason for No VTE Prophylaxis. For stroke, this should be the exception though rather than the norm.

Documentation that the patient is ambulatory the day of or day after hospital admission without "explicit" documentation is not sufficient. The MD/APN/PA or pharmacist must document that VTE prophylaxis is not needed, i.e. "Patient ambulatory - VTE prophylaxis not indicated" in order to select "Yes" for *Reason for No VTE Prophylaxis - Hospital Admission.*

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK, Reason for No VTE Prophylaxis – Hospital Admission
File:

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