Specifications Manual for Joint Commission National Quality Measures (v2020B2)
Posted: 9/2/2020
Home » VTE Prophylaxis Status

Release Notes:
Data Element
Version 2020B2

Name:VTE Prophylaxis Status
Collected For: VTE-6
Definition:Documentation of VTE prophylaxis (mechanical or pharmacologic) administration between the hospital arrival date and the day before the VTE Diagnostic Test order date.
Question:Was VTE prophylaxis administered between the arrival date and the day before the VTE Diagnostic Test order date?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes)      There is documentation that VTE prophylaxis was administered between the day of arrival and the day before the VTE Diagnostic Test order date.

N (No)      There is no documentation that VTE prophylaxis was administered between the day of arrival and the day before the VTE Diagnostic Test order date or unable to determine from medical record documentation.
Notes for Abstraction:
  • If ANY VTE prophylaxis was administered within the specified time frame above, select “Yes.”
  • If more than one acceptable VTE Diagnostic Test was ordered to rule out VTE and both confirmed VTE, select the earliest diagnostic test ordered that confirmed VTE to determine if the patient received VTE prophylaxis.
    Example:
    Patient arrived on 11/1/20XX. A venous Doppler of lower extremities was ordered 11/4/20xx and confirmed a DVT of the right lower extremity. In addition, a CT scan with contrast was ordered on 11/5/20xx and confirmed a PE. Determine if any prophylaxis was administered any time between the hospital arrival date of 11/1/20XX and 11/3/20xx. If no prophylaxis was given, select “No.”
  • If the VTE Diagnostic Test was ordered the day of or the day after the arrival date, select “Yes.”
  • If the patient was admitted and had surgery on day of or day after hospital admission or ICU admission and VTE prophylaxis was administered before the VTE Diagnostic Test was ordered, select “Yes.”
    Example:
    MVA arrives 10/09. Lovenox ordered and held for surgery 10/10. Lovenox administered 10/11 at 0140. CTA abdomen ordered 10/11 2100.
  • If the record contains questionable information regarding the administration of VTE prophylaxis the day before the VTE Diagnostic Test was ordered, select “No.”
  • Application of mechanical prophylaxis may be documented by any personnel.
    Example:
    Nursing assistant documentation of IPC application during the allowable time frame is acceptable.
  • Evaluate prophylaxis with documentation of administration only.
    Example:
    The only documentation of prophylaxis is in the physician progress notes under assessment/Plan: “DVT prophylaxis – IPC,” select “No” because there is no documentation of administration.
  • If one pharmacological medication is ordered and another medication is substituted (such as per pharmacy formulary substitution or protocol), select “Yes” if the substitution medication was administered.
    Note: No copy of the formulary or protocol is required in the medical record.
    Example:
    Lovenox is ordered but not administered, and is substituted with Arixtra, which is administered. Select “Yes.”
  • Aspirin is only acceptable as VTE prophylaxis in total hip replacement and total knee replacement surgery.
Suggested Data Sources:
  • Circulator notes
  • Emergency department record
  • Graphic/flow sheets
  • Medication administration record
  • Nursing notes
  • Operative notes
  • Physician notes
  • Preoperative nursing notes
  • Progress notes
  • Radiology reports
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion

A list of the ONLY acceptable diagnostic tests is found in the data element VTE Diagnostic Test.

Refer to Appendix H, Table 2.1 VTE Prophylaxis Inclusion Table.

VTE Prophylaxis Status
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Specifications Manual for Joint Commission National Quality Measures (v2020B2)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

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