Table 1. Sources and definitions of the automated Padua Prediction Score variables.
| Variable | Score d | Automated | Manual | |
|---|---|---|---|---|
| Source | Definition | Source | ||
| Active cancer a | 3 | Admitting Diagnosis list in EHR | ICD-9 149.0–172.99, 174.0–209.99 | Encounter reason for admission, admitting physician history & physical (H&P) admission note at time of index hospital stay (HPI, problem list, A/P); oncology notes in the past 6 months |
| Previous VTE | 3 | Problem list and Admitting Diagnosis list in the EHR | ICD-9 415.1, 415.19. 453.8, 453.9, 671.31–671.50 | Encounter reason for admission, admitting physician H&P admission note |
| Reduced mobility b | 3 | Physician orders in EHR | Bed rest (complete or strict), bed rest with bathroom privileges, bed rest with bedside commode privileges | Physician orders in EHR |
| Thrombophilic condition c | 3 | Problem list and Admitting Diagnosis list in the EHR | ICD-9 289.81 | Encounter reason for admission, admitting physician H&P admission note |
| Recent trauma/surgery | 2 | NA | NA | Surgical procedure encounter, surgical notes, H&P note, or surgical history in H&P note within 30 days of admission |
| Age | 1 | Demographics in EHR | Age from date of birth | Demographics in EHR |
| Heart failure | 1 | Problem list and Admitting Diagnosis list in the EHR | ICD-9 428.x | Encounter reason for admission, Admitting physician H&P admission note |
| Respiratory failure | 1 | Problem list and Admitting Diagnosis list in the EHR | ICD-9 490–494.99, 496.x | Encounter reason for admission, admitting physician H&P admission note |
| Acute myocardial infarction | 1 | Admitting Diagnosis list in EHR; listed as primary reason | ICD-9 410.x | Encounter reason for admission, admitting physician H&P admission note |
| Acute stroke | 1 | Admitting Diagnosis list in EHR; listed as primary reason | ICD-9 430–438.99 | Encounter reason for admission, admitting physician H&P admission note |
| Acute infection | 1 | Admitting Diagnosis list in EHR | ICD-9 1.x-136.99, 460–466.99, 480–488.99,680–686.99, 995.9, 995.90–995.94, | Encounter reason for admission, admitting physician H&P admission note |
| Rheumatological disorder | 1 | Problem list and Admitting Diagnosis list in the EHR | ICD-9 274.9, 696,696,701.0, 715.x 725.x, 710.0–715.99, 720.x | Admitting physician H&P admission note |
| Obesity | 1 | Problem list in EHR and BMI in EHR vitals | ICD-9 278.x or BMI ≥ 30 | Admitting physician H&P admission note and admission height and weight in EHR vitals |
| Hormone treatment | 1 | Pharmacy orders in EHR, outpatient and inpatient | Therapeutic class hormones, pharmaceutical subclass estrogens, estrogen–progestin, vaginal estrogens | Admission medication list in admitting physician H&P admission note |
Abbreviations: A/P, assessment and plan; BMI, body mass index; EHR, electronic health record; HPI, history of present illness; ICD, International Classification of Disease; VTE, venous thromboembolism.
a
Patients with local or distant metastases and/or in whom chemotherapy or radiotherapy has been performed in the previous 6 months.
b
Bed rest with bathroom privileges (either due to patient's limitations or on physician's order) for at least 3 days.
c
Carriage of defects of antithrombin, protein C or S, factor V Leiden, G20210A prothrombin mutation, and antiphospholipid syndrome. 8
d
Low risk of VTE: score < 4.