Form Aw-1.01837 - Prescription / Certificate Of Medical Necessity / Risk Assessment Form
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2PRESCRIPTION / CERTIFICATE OF MEDICAL NECESSITY / RISK ASSESSMENT FORM
PATIENT NAME________________________________________________________ AGE____________ DATE OF BIRTH_____________________
DATE OF SURGERY_________________ TYPE OF SURGERY_________________________________ LOCATION__________________________
DIAGNOSIS______________________________________________________________ ICD-10__________________________________________
DIAGNOSIS______________________________________________________________ ICD-10__________________________________________
PATIENT MEDICAL REVIEW / RISK ASSESSMENT
Each Risk Factor Represents 3 Points
Each Risk Factor Represents 1 Point
Age 75 years or more
Age 40-59 years
Major surgery lasting 2-3 hours
Minor surgery planned
BMI > 50 (venous stasis syndrome)
History of prior major surgery
History of SVT, DVT/PE
Varicose veins
Family history of DVT/PE
History of inflammatory bowel disease
Present cancer or chemotherapy
Swollen legs (current)
Positive Factor V Leiden
Obesity (BMI >30)
Positive Prothrombin 20210A
Acute myocardial infarction (< 1 month)
Elevated serum homocysteine
Congestive heart failure (< 1 month)
Positive Lupis anticoagulant
Sepsis (< 1 month)
Elevated anticardiolipin antibodies
Serious lung disease incl. pneumonia (< 1 month)
Heparin-induced thrombocytopenia (HIT)
Abnormal pulmonary function (COPD)
Other thrombophilia
Medical patient currently at bed rest
Type ______________________________________
Leg plaster cast or brace
Other risk factor __________________________
Each Risk Factor Represents 5 Points
For Women Only (Each Represents 1 Point)
Elective major lower extremity arthroplasty
Oral contraceptives or hormone replacement therapy
Hip, pelvis or leg fracture (< 1 month)
Pregnancy or postpartum (<1 month)
Stroke (< 1 month)
History of unexplained stillborn infant, recurrent
spontaneous abortion (≥3), premature birth with
Multiple trauma (< 1 month)
toxemia or growth restricted infant
Acute spinal cord injury (paralysis) (< 1 month)
Major surgery lasting over 3 hours
Each Risk Factor Represents 2 Points
TOTAL VTE RISK FACTOR SCORE
Age 60-74 years
Total Risk Factor Score
Incidence of DVT
Risk Level
Major surgery (> 60 minutes)
0-1
<10%
Low Risk
Arthroscopic surgery (> 60 minutes)
2
10% - 20%
Moderate Risk
Laparoscopic surgery (> 60 minutes)
3-4
20% - 40%
High Risk
Previous malignancy
40% - 80%
5 or More
Highest Risk
Morbid obesity (BMI >40)
1-5% mortality
Central venous access
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