VENOUS THROMBOEMBOLISM REPORT FORM

File number:
Age: Hospital:
Admission Date ../../201 Discharge date . ./../201
Previous hospital admission with 90
days (if patient admitted in other
hospital please specify) ⧠ Yes ⧠ No Date ./../201
Previous hospital

Gender
 Male  Female
 Pre-Puberty
 On contraceptive Pills
Female
Child bearing period: the patient was pregnant post-natal period
 Menopausal with HRT No HRT
Diagnosis &Co-Morbidity:
Day □ Jan □ Feb □ Mar □ April □May □ June Year:
Date of diagnosis of VTE □ July □ Aug □ Sept □ Oct □ Nov □ Dec

WHAT IS PATIENT’S CATEGORY? □ Medical □ Surgical □ Orthopedic □ Cancer □ Obs-Gyne

□ Others(Specify)……………

1. Which of the following occurred? CHECK ALL THAT APPLY

□ DVT □ PE

If DVT, WITH OR WITHOUT PE, WAS SELECTED IN QUESTION 1, ANSWER QUESTION 2. IF ONLY PE WAS
SELECTED, SKIP QUESTION 2 and 3

2. What was the location of the DVT? CHECK ONE

a) ☐Upper extremity/upper thorax 


b) ☐Lower extremity/pelvis 

c) ☐Both 


3. Which diagnostic test confirmed the DVT? CHECK ALL THAT APPLY:

a. ☐Venous compression ultrasound or duplex ultrasound 


 VENOUS THROMBOEMBOLISM REPORT FORM

b. ☐Magnetic resonance imaging (MRI) 


c. ☐Computed tomography (CT) 


d. Venography 


e. None of the above

4. Prior to the onset of the VTE incident, was a formal VTE risk assessment documented? CHECK ONE:

☐Yes ☐NO ☐Unknown

5. What was the patient’s documented risk of VTE? CHECK ONE:

a. Low risk of VTE

b. Intermediate risk of VTE


c. High risk of VTE


d. Unknown

6. Prior to the onset of the VTE incident, what was the documented risk of bleeding, if any? CHECK ONE:

a. At increased risk for bleeding 


b. Not at increased risk for bleeding 


c. Unknown 


6. Prior to the onset of the VTE incident, was any Pharmacological or mechanical prophylaxis (e.g., graduated
compression stockings, intermittent pneumatic compression device, venous foot pumps) applied? CHECK
ONE:

Yes
 No 
 Unknown

7.Prior to the onset of the VTE incident, was any pharmacological anticoagulant prophylaxis administered?
 VENOUS THROMBOEMBOLISM REPORT FORM

CHECK ONE:

Yes
 No 
 Unknown

7.1. Which of the following best describes why the pharmacologic anticoagulant prophylaxis was not given?
CHECK ALL THAT APPLY:

Contraindicated 


Patient determined to be at low risk 


Risk/benefit did not warrant prophylaxis 


Patient refused 


Unknown 


Other: PLEASE SPECIFY

__________________________________________________________________

8.Prior to the onset of the VTE incident, was any mechanical prophylaxis applied? CHECK ONE:

□ Graduated Compression Stockings

□ Pneumatic Compression Devices
□ Foot Pumps
□ Unknown

9. Which diagnostic test confirmed the PE? CHECK ALL THAT APPLY:

a. Chest CT angiography with contrast 


b. Nuclear medicine pulmonary scan (ventilation/perfusion lung scan, V/Q scan, pulmonary
scintigraphy) 


c. Magnetic resonance imaging (MRI) 


d. Pulmonary angiography 


e. Post-mortem examination finding that PE likely contributed to death of patient 


 VENOUS THROMBOEMBOLISM REPORT FORM

f. None of the above 


10. Outcome

Discharge alive 
 
 Died