Inclusion criteria
- •Adult patients aged 16 years or older
- •Patients admitted to hospital or due to be admitted
- •Patients admitted to selected wards, units, departments or specialties during the audit period
- •Medical, surgical, trauma or specialty inpatient admissions where VTE assessment is required under local policy
- •Electronic, paper or hybrid records depending on local setup
Exclusion criteria & limitations
- •Patients under 16 years old
- •Obstetric or recently pregnant patients unless the tool is locally adapted to maternity-specific guidance
- •Patients not admitted and not due to be admitted unless local policy requires VTE assessment
- •Day-case or outpatient attendances where local policy does not require inpatient VTE assessment
- •Duplicate admissions or duplicate records
- •Cases outside the selected audit period
- •Records unavailable for review
- •Records where local governance approval is required but has not been obtained
- •Direct patient identifiers must not be entered into the tool
Audit criteria (21)
Aligned with NICE NG89, NICE QS201 and local trust VTE policy. Compliance is calculated using Yes and No responses only; Not applicable and Unable to determine are excluded from the denominator.
- C1VTE risk assessment completed where required.Target ≥ 95% · auto-computed from submissions
- C2VTE risk assessment completed within 24 hours of admission.Target ≥ 95% · auto-computed from submissions
- C3VTE risk documented clearly.Target ≥ 95% · auto-computed from submissions
- C4Bleeding risk assessed.Target ≥ 95% · manual review
- C5Bleeding risk documented clearly.Target ≥ 95% · manual review
- C6VTE and bleeding risks balanced when deciding prophylaxis.Target ≥ 95% · manual review
- C7Pharmacological prophylaxis decision documented.Target ≥ 95% · auto-computed from submissions
- C8Pharmacological prophylaxis prescribed where indicated.Target ≥ 95% · manual review
- C9Pharmacological prophylaxis started within the locally agreed target timeframe where indicated.Target ≥ 90% · manual review
- C10Contraindication to pharmacological prophylaxis documented where prophylaxis was not prescribed.Target ≥ 95% · auto-computed from submissions
- C11Renal function considered where pharmacological prophylaxis was relevant.Target ≥ 90% · manual review
- C12Dose adjustment or weight consideration documented where locally required.Target ≥ 90% · manual review
- C13Mechanical prophylaxis decision documented where relevant.Target ≥ 90% · manual review
- C14Mechanical prophylaxis prescribed, applied or arranged where indicated.Target ≥ 90% · manual review
- C15Contraindication to mechanical prophylaxis documented where not used.Target ≥ 90% · manual review
- C16Patient information about VTE risk and prophylaxis documented where required.Target ≥ 85% · manual review
- C17VTE and bleeding risk reassessed at consultant review, clinical change or other locally required trigger.Target ≥ 90% · auto-computed from submissions
- C18Reassessment completed within the locally agreed timeframe where required.Target ≥ 90% · manual review
- C19Reason for delayed, missing or incomplete assessment documented where applicable.Target ≥ 85% · manual review
- C20Documentation is clear enough for another clinician or pharmacist to understand the VTE assessment and prophylaxis plan.Target ≥ 90% · manual review
- C21Any VTE, bleeding or anticoagulation-related safety concern was escalated or actioned where identified.Target ≥ 100% · manual review