VTE data elements
| Variable . | Level 1 (basic) . | Level 2 (intermediate) . | Level 3 (comprehensive) . |
|---|---|---|---|
| Date of acute VTE | Date VTE diagnosed: MM/DD/YYYY | Date VTE diagnosed: MM/DD/YYYY | Date VTE diagnosed: MM/DD/YYYY |
| Anticoagulant therapy at time of event | Antithrombotic therapy form | Antithrombotic therapy form | Antithrombotic therapy form |
| Type and location of VTE | Type and location of VTE (select one) ☐ DVT ☐ Lower extremity DVT ☐ Upper extremity/neck DVT ☐ Non-limb DVT ☐ Superficial vein thrombosis ☐ PE Fatal PE ☐ Yes ☐ No ☐ Unknown | Type and location of VTE (select all that apply): ☐ DVT ☐ Lower extremity DVT Select location(s): ☐ Right ☐ Left Select the most proximal involved veins: ☐ Proximal veins (IVC, iliac, femoral, popliteal veins) ☐ Calf veins (anterior tibial, posterior tibial, peroneal, soleal, gastrocnemius) ☐ Upper extremity/neck DVT Select location(s): ☐ Right ☐ Left ☐ Non-limb venous thrombosis ☐ Splanchnic vein (portal, splenic, or mesenteric) ☐ Cerebral venous sinus ☐ Renal vein ☐ Gonadal veins ☐ Other (specify): ___________________ ☐ Superficial vein thrombosis ☐ PE (choose one): Fatal PE ☐ Yes ☐ No ☐ Unknown Select location(s): ☐ Unknown location (ie, presumed PE due to inability to obtain imaging and based on clinical presentation and ancillary tests [eg, echocardiogram]) ☐ Subsegmental pulmonary arteries only ☐ Segmental or larger pulmonary artery | Type and location of VTE (select all that apply): ☐ DVT ☐ Lower extremity DVT Select location(s): ☐ Right ☐ Left Select the most proximal involved vein: ☐ IVC ☐ Iliac vein ☐ Femoral vein ☐ Popliteal vein ☐ Calf veins (anterior tibial, posterior tibial, peroneal, soleal, gastrocnemius) Associated with central venous catheter? ☐ Yes ☐ No ☐ Unknown ☐ Upper extremity/neck DVT Select location(s): ☐ Right ☐ Left Select most proximal involved vein: ☐ Distal to axillary vein (radial, ulnar) ☐ Axillary ☐ Subclavian ☐ Internal jugular ☐ Brachiocephalic ☐ Innominate ☐ SVC Associated with central venous catheter? ☐ Yes ☐ No ☐ Unknown ☐ Non-limb venous thrombosis ☐ Splanchnic vein (portal, splenic, or mesenteric) ☐ Cerebral venous sinus ☐ Renal vein ☐ Gonadal veins ☐ Other (specify): ___________________ ☐ Superficial vein thrombosis Select location(s): ☐ Lower extremity ☐ Upper extremity Associated with peripheral or central venous catheter? ☐ Yes ☐ No ☐ Unknown ☐ PE (choose one): Fatal PE ☐ Yes ☐ No ☐ Unknown Select location(s): ☐ Unknown location (ie, presumed PE due to inability to obtain imaging and based on clinical presentation and ancillary tests [eg, echocardiogram]) ☐ Subsegmental pulmonary arteries only ☐ Segmental or larger pulmonary artery |
| Symptoms of VTE | ☐ Asymptomatic, detected on systematic VTE screening test ☐ Incidental finding on a test performed for another indication ☐ Symptoms triggered testing ☐ Unknown | ☐ Asymptomatic, detected on systematic VTE screening test ☐ Incidental finding on a test performed for another indication ☐ Symptoms triggered testing ☐ Unknown | |
| Diagnosis of VTE | ☐ Objectively confirmed using diagnostic imaging (eg, CTPA, V/Q scan, ultrasound, MRI) ☐ Clinical/empirical diagnosis only → indicate reason(s) objective confirmation not done: ☐ Unable to obtain imaging due to clinical status of patient (eg, hemodynamically unstable) ☐ Unable to obtain imaging due to resource limitations (eg, timely imaging not available) ☐ Unable to obtain imaging due to need for patient isolation or risk of infectious exposure ☐ Other (specify): ____________ ☐ Unknown | ☐ Objectively confirmed using diagnostic imaging (eg, CTPA, V/Q scan, ultrasound, MRI) ☐ Clinical/empirical diagnosis only → indicate reason(s) objective confirmation not done: ☐ Unable to obtain imaging due to clinical status of patient (eg, hemodynamically unstable) ☐ Unable to obtain imaging due to resource limitations (eg, timely imaging not available) ☐ Unable to obtain imaging due to need for patient isolation or risk of infectious exposure ☐ Other (specify): ____________ ☐ Unknown | ☐ Objectively confirmed using diagnostic imaging (select all that apply) PE diagnostic findings → ☐ High-probability V/Q or positive SPECT V/Q ☐ Intraluminal filling defect on CTPA ☐ Other (specify): __________________ DVT diagnostic findings → ☐ Lack of compressibility of a deep vein on compression ultrasound ☐ Intraluminal filling defect on CT venography ☐ Intraluminal filling defect on MRI/MRV ☐ Other (specify): ___________________ ☐ Clinical/empirical diagnosis only → indicate reason(s) objective confirmation not done: ☐ Unable to obtain imaging due to clinical status of patient (eg, hemodynamically unstable) ☐ Unable to obtain imaging due to resource limitations (eg, timely imaging not available) ☐ Unable to obtain imaging due to need for patient isolation ☐ Unknown |
| Antithrombotic treatment of VTE | Antithrombotic therapy form | ||
| Additional interventions | Additional interventions for VTE (select all that apply) ☐ Thrombolysis–systemic ☐ Thrombolysis–catheter directed ☐ Mechanical thrombectomy ☐ IVC filter insertion ☐ Other (specify): _________________________ ☐ Unknown |
| Variable . | Level 1 (basic) . | Level 2 (intermediate) . | Level 3 (comprehensive) . |
|---|---|---|---|
| Date of acute VTE | Date VTE diagnosed: MM/DD/YYYY | Date VTE diagnosed: MM/DD/YYYY | Date VTE diagnosed: MM/DD/YYYY |
| Anticoagulant therapy at time of event | Antithrombotic therapy form | Antithrombotic therapy form | Antithrombotic therapy form |
| Type and location of VTE | Type and location of VTE (select one) ☐ DVT ☐ Lower extremity DVT ☐ Upper extremity/neck DVT ☐ Non-limb DVT ☐ Superficial vein thrombosis ☐ PE Fatal PE ☐ Yes ☐ No ☐ Unknown | Type and location of VTE (select all that apply): ☐ DVT ☐ Lower extremity DVT Select location(s): ☐ Right ☐ Left Select the most proximal involved veins: ☐ Proximal veins (IVC, iliac, femoral, popliteal veins) ☐ Calf veins (anterior tibial, posterior tibial, peroneal, soleal, gastrocnemius) ☐ Upper extremity/neck DVT Select location(s): ☐ Right ☐ Left ☐ Non-limb venous thrombosis ☐ Splanchnic vein (portal, splenic, or mesenteric) ☐ Cerebral venous sinus ☐ Renal vein ☐ Gonadal veins ☐ Other (specify): ___________________ ☐ Superficial vein thrombosis ☐ PE (choose one): Fatal PE ☐ Yes ☐ No ☐ Unknown Select location(s): ☐ Unknown location (ie, presumed PE due to inability to obtain imaging and based on clinical presentation and ancillary tests [eg, echocardiogram]) ☐ Subsegmental pulmonary arteries only ☐ Segmental or larger pulmonary artery | Type and location of VTE (select all that apply): ☐ DVT ☐ Lower extremity DVT Select location(s): ☐ Right ☐ Left Select the most proximal involved vein: ☐ IVC ☐ Iliac vein ☐ Femoral vein ☐ Popliteal vein ☐ Calf veins (anterior tibial, posterior tibial, peroneal, soleal, gastrocnemius) Associated with central venous catheter? ☐ Yes ☐ No ☐ Unknown ☐ Upper extremity/neck DVT Select location(s): ☐ Right ☐ Left Select most proximal involved vein: ☐ Distal to axillary vein (radial, ulnar) ☐ Axillary ☐ Subclavian ☐ Internal jugular ☐ Brachiocephalic ☐ Innominate ☐ SVC Associated with central venous catheter? ☐ Yes ☐ No ☐ Unknown ☐ Non-limb venous thrombosis ☐ Splanchnic vein (portal, splenic, or mesenteric) ☐ Cerebral venous sinus ☐ Renal vein ☐ Gonadal veins ☐ Other (specify): ___________________ ☐ Superficial vein thrombosis Select location(s): ☐ Lower extremity ☐ Upper extremity Associated with peripheral or central venous catheter? ☐ Yes ☐ No ☐ Unknown ☐ PE (choose one): Fatal PE ☐ Yes ☐ No ☐ Unknown Select location(s): ☐ Unknown location (ie, presumed PE due to inability to obtain imaging and based on clinical presentation and ancillary tests [eg, echocardiogram]) ☐ Subsegmental pulmonary arteries only ☐ Segmental or larger pulmonary artery |
| Symptoms of VTE | ☐ Asymptomatic, detected on systematic VTE screening test ☐ Incidental finding on a test performed for another indication ☐ Symptoms triggered testing ☐ Unknown | ☐ Asymptomatic, detected on systematic VTE screening test ☐ Incidental finding on a test performed for another indication ☐ Symptoms triggered testing ☐ Unknown | |
| Diagnosis of VTE | ☐ Objectively confirmed using diagnostic imaging (eg, CTPA, V/Q scan, ultrasound, MRI) ☐ Clinical/empirical diagnosis only → indicate reason(s) objective confirmation not done: ☐ Unable to obtain imaging due to clinical status of patient (eg, hemodynamically unstable) ☐ Unable to obtain imaging due to resource limitations (eg, timely imaging not available) ☐ Unable to obtain imaging due to need for patient isolation or risk of infectious exposure ☐ Other (specify): ____________ ☐ Unknown | ☐ Objectively confirmed using diagnostic imaging (eg, CTPA, V/Q scan, ultrasound, MRI) ☐ Clinical/empirical diagnosis only → indicate reason(s) objective confirmation not done: ☐ Unable to obtain imaging due to clinical status of patient (eg, hemodynamically unstable) ☐ Unable to obtain imaging due to resource limitations (eg, timely imaging not available) ☐ Unable to obtain imaging due to need for patient isolation or risk of infectious exposure ☐ Other (specify): ____________ ☐ Unknown | ☐ Objectively confirmed using diagnostic imaging (select all that apply) PE diagnostic findings → ☐ High-probability V/Q or positive SPECT V/Q ☐ Intraluminal filling defect on CTPA ☐ Other (specify): __________________ DVT diagnostic findings → ☐ Lack of compressibility of a deep vein on compression ultrasound ☐ Intraluminal filling defect on CT venography ☐ Intraluminal filling defect on MRI/MRV ☐ Other (specify): ___________________ ☐ Clinical/empirical diagnosis only → indicate reason(s) objective confirmation not done: ☐ Unable to obtain imaging due to clinical status of patient (eg, hemodynamically unstable) ☐ Unable to obtain imaging due to resource limitations (eg, timely imaging not available) ☐ Unable to obtain imaging due to need for patient isolation ☐ Unknown |
| Antithrombotic treatment of VTE | Antithrombotic therapy form | ||
| Additional interventions | Additional interventions for VTE (select all that apply) ☐ Thrombolysis–systemic ☐ Thrombolysis–catheter directed ☐ Mechanical thrombectomy ☐ IVC filter insertion ☐ Other (specify): _________________________ ☐ Unknown |
CT, computed tomography; CTPA, computed tomography pulmonary angiogram; DVT, deep vein thrombosis; IVC, inferior vena cava; MRI, magnetic resonance imaging; MRV, magnetic resonance venography; PE, pulmonary embolism; SPECT, single-photon emission computed tomography; SVC, superior vena cava; V/Q, ventilation/perfusion.