Specifications Manual for Joint Commission National Quality Measures (v2020A2)
Posted: 10/30/2019
Home » VTE Prophylaxis

Release Notes:
Data Element
Version 2020A2

Name:VTE Prophylaxis
Collected For: STK-1
Definition:The type of venous thromboembolism (VTE) prophylaxis documented in the medical record.
Question:What type of VTE prophylaxis was documented in the medical record?
Allowable Values:

1     Low dose unfractionated heparin (LDUH)

2     Low molecular weight heparin (LMWH)

3     Intermittent pneumatic compression devices (IPC)

5     Factor Xa Inhibitor

6     Warfarin

7     Venous foot pumps (VFP)

8     Oral Factor Xa Inhibitor

A     None of the above or not documented or unable to determine from medical record documentation
Notes for Abstraction:
  • No value should be selected more than once. If a Value of "A" is selected, no other selection should be recorded.
    Lovenox is ordered and substituted with dalteparin. Only abstract Value "2" once, as both are LMWH.
  • Application of mechanical prophylaxis may be documented by any personnel.
    Nursing assistant documentation of IPC application during the allowable timeframe is acceptable.
  • Selection of Allowable Values 1-8 includes any prophylaxis that was administered in the allowable time frame.
    If a patient was admitted on 12/8/20xx and had IPCs applied at 13:00 on 12/09/20xx and LMWH was administered at 22:00 on 12/8/20xx, select Values “2” and “3.”
  • Only select prophylaxis if there is documentation that it was administered. Documentation in the physician progress notes under assessment/Plan: “DVT prophylaxis – IPC” is not enough to select Value “3.”
  • If one pharmacological medication is ordered and another medication is substituted (such as per pharmacy formulary substitution or protocol), abstract the medication administered.
    Note: No copy of the formulary or protocol is required in the medical record.
    Lovenox is ordered, but not received and is substituted with fondaparinux sodium, which is received by the patient. Abstract fondaparinux sodium as Value “5” for VTE Prophylaxis and abstract the date it was administered for VTE Prophylaxis Date.
  • Abstract ALL VTE prophylaxis(s) that was administered on the day of or the day after hospital admission. If no VTE prophylaxis was administered during this timeframe, select “A.”
  • VTE Prophylaxis administered in the ED or Observation prior to the hospital admission order is not sufficient.
  • Emergency Department record
  • Graphic/flow sheets
  • Medication administration record
  • Nursing notes
  • Physician notes
  • Progress notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Refer to Appendix H, Table 2.1 VTE Prophylaxis Inclusion Table. None

VTE Prophylaxis
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Specifications Manual for Joint Commission National Quality Measures (v2020A2)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)


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