<p>Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), poses a significant clinical challenge, particularly among hospitalized medical patients. Despite established guidelines, adherence to VTE prophylaxis remains suboptimal, leading to preventable morbidity and mortality. This retrospective study aimed to investigate anticoagulant prescribing practices for VTE prophylaxis among elderly patients admitted to internal medicine wards in a tertiary hospital in Malaysia. Additionally, the study evaluated adherence to and appropriateness of anticoagulant use for VTE prophylaxis in this setting. The study included all patients aged 70 years and older admitted to internal medicine wards over a 1-year period. Data were collected through detailed chart abstraction, including demographic information, clinical history, and specific indications for anticoagulant therapy. Adherence to Malaysian clinical practice guidelines was assessed using validated risk assessment models, including the Padua Prediction Score and the IMPROVE Bleeding Risk Score. A total of 1013 patients were included in the study, and only 16.5% (<i>n</i> = 167) received thromboprophylaxis. Demographic and clinical characteristics revealed a predominantly elderly population with various comorbidities. The majority of patients were at high risk of VTE, with notable risk factors including acute infection, heart/respiratory failure, and reduced mobility. Adherence to guidelines was suboptimal, with 31.0% of patients receiving inappropriate thromboprophylaxis. Factors contributing to inappropriate management included interrupted prophylaxis, delayed initiation, and unnecessary administration. Despite established guidelines, adherence to VTE prophylaxis remains a challenge among elderly hospitalized medical patients in Malaysia. The study highlights the need for targeted interventions to improve guideline adherence and appropriate anticoagulant prescribing practices in this population.</p>