Risk of blood clot – assess and chart
By Medical Director , Hugh Lees and VTE Programme Manager , Lorraine Wilson .
You may have noticed new posters in clinical areas like this one . This is part of our programme to improve documentation of VTE risk assessments .
Improving VTE Prevention documentation
• The VTE PREVENTION section of the medication chart must be dated and signed by medical staff .
• Any prophylaxis must be prescribed this is required for both pharmaceutical and mechanical prophylaxis ( eg compression stockings and Sequential Compression Devices such as foot pumps ).
• Where no prophylaxis is indicated the reason must be given by ticking either ‘ Low risk of VTE ’ or ‘ High bleeding risk ’
Patients in hospitals can sometimes develop lifethreatening blood clots - also known as venous thromboembolisms ( VTEs ). There are different views about the best way to manage this risk but one thing everyone agrees on is that all in-patients should be risk assessed .
Prescribers :
Doctors , Midwives , Nurse Practitioners & Authorised Pharmacists
Pharmacists :
Doctors and other Prescribers ( eg Midwives , authorised Pharmacists and Nurse Practitioners ), are required to document VTE risk assessment and decision-making in the medication chart . Sometimes investigators ( Coroner or Health Commissioner ) ask for evidence from health records showing a patient received the proper stand of care ; completing the VTE PREVENTION section ( page 6 in the medication chart ) demonstrates that proper standard of care has been given by the Prescriber managing VTE risk .
Please help us improve our documentation by completing the VTE PREVENTION section of the medication chart ( date , sign and indicate prophylaxis using the tick-boxes ).
It would be a great help if you were to take advantage of any opportunity to promote this core message to your colleagues .
Nurses :
Only apply compression stockings and / or foot pumps when these have been prescribed by a doctor who has dated and signed the VTE PREVENTION section of the medication chart and indicated that they should be applied .
Anticoagulant prophylaxis should only be prescribed where the VTE PREVENTION section of the medication chart has been completed by a doctor .
Where an anticoagulant has been charted , but you notice the VTE PREVENTION section of the medication chart has not been completed , please discuss this with the prescriber or patient ’ s doctor .
Other members of the health care team need easy access to the Prescriber ’ s VTE risk assessment and decision-making and it helps when it ’ s always found in the same place . For example Nurses need to check that compression stockings or foot pumps have been prescribed before applying them to patients . Pharmacists need to know that risks have been assessed before dispensing anticoagulants - in some hospitals where medicines are now managed electronically pharmacies don ’ t dispense anticoagulants unless the prescriber first completes the VTE PREVENTION section .
You might notice medication charts being audited lately – and we ’ ve already noticed a big improvement . The poster highlights
Where an anticoagulant has been charted , but you notice the VTE PREVENTION section of the medication chart has not been completed please discuss this with the patient ’ s doctor . key messages and is used in education sessions , especially where Consultants and Registrars are leading by example to improve documentation within their teams . Those in charge of clinical areas can put up a poster where Prescribers often sit to serve as a reminder .
Innovators get ready
The 2017 Innovation Awards take place in October . The Clinical School Education team will be calling for applications from BOPDHB employees and contractors in July .
Definition of innovation 1 . the introduction of something new 2 . a new idea , method , or device https :// www . merriam-webster . com / dictionary / innovation
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