Risk Assessment

Patient Groups at Risk

Particular patient groups are at an increased risk of developing hospital-associated VTEs. These patients should be assessed for VTE risk and provided appropriate prophylaxis where required.

These patient groups include:

  • All adult patients admitted to hospital
  • Adult patients being discharged from an Emergency Department with significantly reduced mobility relative to their normal state
  • Adult patients undergoing planned surgical interventions
  • All pregnant and post-partum women:
    • During the first antenatal review and/or during booking;
    • During a hospital admission (for either pregnancy or non-pregnancy related complaint);
    • Immediately after birth

Assessing VTE Risk

A VTE risk assessment must be completed within 24 hours of admission to hospital. A standardised risk assessment tool must be made available in all NSW hospitals for use by doctors.

A Venous Thromboembolism VTE Risk Assessment Tool has been developed. It can now be ordered via the Stream Solutions online ordering system. Stock Code: NH700015

An electronic version of the tool is available as a package in the state based build for implementation in local Electronic Medical Records (eMR2). Internationally, electronic solutions have been effective in improving VTE prevention processes and reducing rates of hospital-associated VTE.

Documenting VTE Risk

Doctors must document that a risk assessment has been completed and the outcome of the risk assessment.

The National Inpatient Medication Chart (NIMC) includes a dedicated VTE section (not included on the long-stay version).


Medical officers should use this section to document when a risk assessment has been completed.

Additional areas for documentation may include:

  • the patients' health care record
  • approved risk assessment tools
  • other locally approved forms, such as patient care plans
  • electronic medical record

Reassessing VTE Risk

Reassessment is required to ensure that appropriate methods of VTE prophylaxis are used, that VTE prophylaxis is being used correctly and to identify adverse events resulting from VTE prophylaxis or its absence.  VTE risk needs to be reassessed:

  • Regularly (at least every 7 days)
  • As clinical condition changes e.g. after surgery, changes in mobility
  • At transfer of care
  • On discharge, with particular consideration regarding the need for extended prophylaxis