-:‫اسم المريض‬

‫الرقم الطبى‬
-: ‫العمر‬ -: ‫الجنس‬ -: ‫تاريخ الدخول‬
Deep Vein Thrombosis (DVT) Prophylaxis (Adult) -: ‫الدور‬ -: ‫القسم‬
Order Thrombosis Risk Factor reassessment -: ‫رقم اذن القبول‬
‫تقيم الجلطات الوريدية للكبار‬ -: ‫المعامله الماليه‬
Diagnosis: ……………………………………………… Date: / /

Complete the risk assessment to determine your patient's rusk level venous
thromboembolism(VTE)
5point 3point 2point 1point
Per risk factor Per risk factor Per risk factor Per risk factor
Stroke(˂1month) Age ≥ 75 years Age 61-74 years Age 41-60 years

Minor surgery
History of VET Arthroscopic surgery BMI˃25 kg/m2
Swollen legs
Elective FamilyHistory of Major open surgery Varicose veins
arthroplasty VET V Leiden (˃45 minutes) Pregnancy or postpartum
Prothrombin Laparoscopic History of unexplained or
20210A surgery (˃45 recurrent spontaneous
minutes) abortion
Oral contraceptive or
hormone replacement
Hip, pelvis or leg Lupus anticoagulant Malignancy Sepsis (˂1 month)
fracture Heparin-induced Serious lung disease,
thrombocytopenia including pneumonia (˂1
month)
Anti cardicolipin Confined to bed Abnormal pulmonary
antibodies (˃72 hours) Function
Acute myocardial
infarction
Acute spinal Elevated serum Immobilizing plaster Congestive heart failure
cord injury (˂1 Homocysteine cast (˂1 month)
month) History of inflammatory
bowel disease
Other congenital or Central venous Medical patient at bed rest
acquired access Other risk factors:
thrombophilia if yes: …………………………
…………………… …………………………
…………………… …………………
…………………….
Subtotal: ……….. Subtotal:……………….. Subtotal: ……………… Subtotal: ………………..
First Assessment:
 Total risk factor score: ……………………. Decision: …………………………………………………..

Physician Signature: …………………….. Date: / / Time: ….. : ……

Second Assessment:

Total risk factor score: ……………………. Decision: …………………………………………………..

Physician Signature: …………………….. Date: / / Time: ….. : ……

Third Assessment:
Total risk factor score: ……………………. Decision: …………………………………………………..

Physician Signature: …………………….. Date: / / Time: ….. : ……

Contraindications
Relative contra-indications Absolute contra-indications
5. Intracranial mass. 1. Hemorrhage
6. Neurosurgical procedure. 2. Bleeding disorder, known or tendency.
7. Uncontrolled hypertension. 3. Platelet count unable to be sustained
8. Pelvic fracture within past 48 hours. >50,000/mm3
9. Lumbar puncture or epidural catheter removal. 4. Uncontrolled HTN
(SBP˃185and/orDBP˃100mmHg)
Based on Total Risks Factors, Select one the following
Risk score=2(moderate risk) : Early ambulation and Risk score˂ 1 (low risks)
the following
Enoxaparin (Heparin®) □ Early ambulation
□30 mg /24hr SC  5000 units /12hr SC
□40 mg /24hr SC
□ Sequential compression device(SCD) or Elastic
compression stockings
Risk score≥5(highest risk) : Early ambulation and Risk score=3-4(high risk) : Early ambulation
the following and the following
Enoxaparin (Heparin®) Enoxaparin (Heparin®)
□30 mg /24hr SC 5000 units /8 hr SC □30 mg /24hr SC 5000 units /8 hr SC
□40 mg /24hr SC □40 mg /24hr SC
Plus □Sequential compression device(SCD) or OR □ +/- Sequential compression device(SCD)
Elastic compression stockings Elastic compression stockings
□ No order for prophylaxis reason:
 Lab: Check baseline CBC and at least every 72 hr. thereafter.
 Notify physician if platelet count˂ 100000 or drop by 50% from baseline
 Reference: Caprini score for VTE prophylaxis