Background The aim of the study was to examine the gaps in documentation of VTE risk stratification scoring according to the Padua score in the electronic medical record (BestCare system) for medically admitted patients, and to identify the current practice of VTE prophylaxis according to any guidelines in use.

Methods A concurrent cohort of all patients admitted to the Internal Medicine Department was studied from 1 September to 30 November 2018 for the compliance of VTE prophylaxis documentation and VTE prophylaxis prescription. Data were analyzed in December 2018, a PDSA (plan-do-study-act) model was applied, and educational intervention through presentations and WhatsApp group notifications to the whole medicine team conducted. Monthly data collection was started from January 2019 onwards to identify the improvement after implementation of interventions in our practice. VTE prescription according to National Institute of Health and Care Excellence (NICE) clinical guidelines 2010 was added in BestCare as none existed.

Results A total of 405 patients were studied from 1 September to 30 November 2018. Compliance to Padua score documentation was 94% (n=382). 67% (n=142) patients were at risk of VTE. Among these patients, VTE prophylaxis prescription was not done in 33%. After implementing interventions in our practice, prospective data collected in January-February 2019 showed significant improvement in complete and appropriate documentation of VTE prophylaxis to 99% and 98% VTE prescription according to NICE clinical guidelines 2010. Monthly data will be collected on a regular basis to ensure compliance.

Conclusion The VTE risk stratification documentation and VTE prophylaxis prescription showed promising results after PDSA implementation, introduction of NICE clinical guidelines 2010, and educational interventions. This change has shown an improvement in patient quality of care and safety outcomes.