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Case Study 05 - Discussion Part 3 - Transfusion Record (Sample)
 

TraQ Program of the BC PBCO

Home Case Studies O-Level Case Study O5: Adverse event following plasma transfusion Case Study 05 - Discussion Part 3 - Transfusion Record (Sample)
Thursday, 23 March 2017

Case Study 05 - Discussion Part 3 - Transfusion Record (Sample)

*This is a partial form only to show some of the key items that need documentation.

BLOOD & BLOOD COMPONENT TRANSFUSION RECORD
Use a new form for each unit of blood and blood product

If blood component cannot be immediately transfused,
return to Transfusion Service within 30 minutes of issue to avoid wasting product.

MINIMUM ASSESSMENT PROTOCOL

1. Monitor patient closely for first 15 minutes

2. Vital Signs

i) Pre-transfusion ii) Start of transfusion (when product enters patient)

iii) 15 min into transfusion iv) Q1 hr  

v) Completion of transfusion

 

 

 

 

 

 

 

 

 

Pre-Medication Given

 Yes  No

Blood Product

 RBC Platelets

 Albumin  FFP

 Other ____________________

 

 

Expiry Date: __________________

Recipient:

ABO Group ______ Rh ______

Donor:

ABO Group ______ Rh ______

Checked By (1): ______________

Checked By (2): _____________

Hung By: ________________

Start Time_______

Ended By: __________________

End Time ______

  Valid consent

 Patient education

 

Time

Infusion Rate

Temp Heart Rate Resp. Rate

BP

Initials

Pre

 

 

 

 

 

 

Start

 

 

 

 

 

 

15 min

 

 

 

 

 

 

1 hour

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Completion

 

 

 

 

 

 

Signatures

Initials

Signatures

Initials

 

 

 

 

 

 

 

 

       

Comments: (signs & symptoms of any adverse reaction)

 

 

 

 

 fever chills urticaria pruritis

hematuria anuria bleeding pain (e.g., lumbar, joint)

 Ý pulsedyspnea nausea vomiting  

 

For all suspected reactions: Verify Patient ID with Blood Product Information

 

Adverse Reaction:  No  Yes If yes, 

 Physician notified
 Transfusion Service notified
 Reaction documented – see above
 Send remaining blood products to Transfusion Service
 Fax Transfusion Record to Transfusion Service
 

Signature ___________________________

Date &Time ______________

 

 

 

 

 

Last modified on Wednesday, 06 April 2011 14:24