Autar DVT Risk Assessment Scale

ADDRESSOGRAPH

SPECIAL RISK CATEGORY

Name:

Oral contraceptive:
20-35 yrs
35+ yrs

TRAUMA RISK CATEGORY

Score
1
2

Unit No:
Pregnancy/Puerperium
Ward:

AGE SPECIFIC GROUP

Age Group
10-30
31-40
41-50
51-60
61+

Score
0
1
2
3
4

Build
Under weight
Average
Overweight

BMI
16-19
20-25
26-30

Score
0
1
2

MOBILITY
Score
Ambulant
Limited (users aids self)
Very limited (needs help)
Chair bound
Complete bed rest

Score < 6
Score 7-10
Score 11-14
Score 15>

Head
Chest
Spinal
Pelvic
Lower limb

1
1
2
3
4

SURGICAL INTERVENTIONS

No risk
Low Risk (<10%)
Moderate Risk (11-40%)
High Risk (>41%)

THROMBOPROPHYLAXIS
Leg Elevation
Graduated Elastic Compression stockings (GECS)
Pneumatic Compression (PC)
Intermittent or
Continuous
Heparin

Heparin Sodium ( standard/unfractionated)

Calciparine (heparin calcium)
Minihep (heparin sodium)
Minehep calcium (heparin calcium)
Monoparin (heparin sodium)
Monoparin calcium (heparin calcium
Multiparin (heparin sodium)
Pump-hep (heparin sodium
Unihep (heparin sodium)
Uniparin (heparin sodium)

Low molecular Weight Heparin

0
1
2
3
4

Score

ASSESSMENT PROTOCOL

Please tick the appropriate prescribed DVT prophylaxis

BUILD BODY MASS

INDEX(BMI)

Score items(s) ONLY pre-operative

Fragmin (dalteparin sodium

Clexane (enoxaparin Heparin)
Innohep (tinzaparin)
Logiparin (tinzaparin)

Warfarin
Others, please specify:
No Prophylaxis

Score only ONE appropriate item

Score

Minor Surgery (<30 mins)

Major Surgery
Emergency Major Surgery
Thoracic
Abdominal
Urological
Neurosurgical
Orthopaedic
HIGH RISK DESEASES

1
2
3
3
3
3
3
4

Score
1
2
2
2
3
4
5
6
7

Ulcerative Colitis
Anaemia: Sickle Cell
Polycythaemia
Haemolytic
Chronic Heart Disease
Myocardial Infraction
Malignancy
Varicose Viens
Previous DVT or CVA

SCORING (within 24 hours of admission)

Identify appropriate items, add record score below

Assesor

San Antonio Association of Operating Room Nurses. Autar DVT Risk Assessment Scale.
Retrieved 10-25-2009.
http://home.earthlink.net/~kremmert/Competencies/Autar%20DVT%20Risk%20Assessment%20Scale.doc

Date

Score