25 noadmpro Is there documentation of a reason VTE prophylaxis 1,2,95 Documentation of the reason for not administering VTE prophylaxis must be written by the day after hospital admission was not administered the day of or day after hospital Will be auto-filled as 95 or Surgery End Date (for surgeries that start the day of or the admission (or day of surgery or day after surgery end if vteproA <> -1 It is not necessary to review day after hospital admission). date)? documentation outside of this timeframe to answer this data element. 1. Yes Physician/APN/PA or pharmacist documentation of reason for 2. No not administering VTE prophylaxis is required with the 95. Not applicable EXCEPTION of nursing documentation of patient/family refusal or completion of a VTE risk assessment form by a nurse. A completed VTE risk assessment within this timeframe is an acceptable source for this data element. For patients on continuous IV heparin therapy the day of or day after hospital admission, select “Yes.” For patients on warfarin therapy prior to admission, but placed on hold due to select “high INR”, “Yes.” Both the pharmacological and mechanical approaches must be assessed to answer to this data element. For example, if “Yes” there is physician documentation of no “bleeding, pharmacologic prophylaxis there must also be needed”, documentation of a reason why no mechanical prophylaxis was administered to select If either type of prophylaxis was “Yes.” administered, then no reason is required. If documentation of VTE Prophylaxis is “No needed” written, then it will be inferred that both mechanical and pharmacological options were not indicated for the patient. Patient/family refusal may be documented by a nurse, but must be documented on the day of or the day after hospital admission. Patient/family refusal of any form of prophylaxis is acceptable to select “1”. For the purposes of this data element, physician/APN/PA, or pharmacist documentation that the patient is at low risk for VTE or explicit documentation that the patient does not need VTE prophylaxis is acceptable.
25 noadmpro Is there documentation of a reason VTE prophylaxis was not administered the day of or day after hospital admission (or day of surgery or day after surgery end date)? 1. Yes 2. No 95. Not applicable 1,2,95 Will be auto-filled as 95 if vteproA <> -1 Documentation of the reason for not administering VTE prophylaxis must be written by the day after hospital admission or Surgery End Date (for surgeries that start the day of or the day after hospital admission). It is not necessary to review documentation outside of this timeframe to answer this data element. Physician/APN/PA or pharmacist documentation of reason for not administering VTE prophylaxis is required with the EXCEPTION of nursing documentation of patient/family refusal or completion of a VTE risk assessment form by a nurse. A completed VTE risk assessment within this timeframe is an acceptable source for this data element. For patients on continuous IV heparin therapy the day of or day after hospital admission, select “Yes.” For patients on warfarin therapy prior to admission, but placed on hold due to “high INR”, select “Yes.” Both the pharmacological and mechanical approaches must be assessed to answer “Yes” to this data element. For example, if there is physician documentation of “bleeding, no pharmacologic prophylaxis needed”, there must also be documentation of a reason why no mechanical prophylaxis was administered to select “Yes.” If either type of prophylaxis was administered, then no reason is required. If documentation of “No VTE Prophylaxis needed” is written, then it will be inferred that both mechanical and pharmacological options were not indicated for the patient. Patient/family refusal may be documented by a nurse, but must be documented on the day of or the day after hospital admission. Patient/family refusal of any form of prophylaxis is acceptable to select “1”. For the purposes of this data element, physician/APN/PA, or pharmacist documentation that the patient is at low risk for VTE or explicit documentation that the patient does not need VTE prophylaxis is acceptable.
VTE.docx