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Blood Transfusion Form

This document is a blood transfusion form containing information about a patient receiving a blood transfusion. It includes the patient's name, age, sex, address, blood type, source of blood, expiration time and date. It specifies the type of blood component being transfused and whether it is crossmatched or uncrossmatched. The form is signed by the patient or legal guardian and attending physician authorizing the transfusion. It documents the crossmatching, receiving, and administering of the blood unit and records the patient's vital signs before and after the transfusion. Any reactions or issues during the transfusion are noted.

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GMCH Laboratory
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© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
1K views

Blood Transfusion Form

This document is a blood transfusion form containing information about a patient receiving a blood transfusion. It includes the patient's name, age, sex, address, blood type, source of blood, expiration time and date. It specifies the type of blood component being transfused and whether it is crossmatched or uncrossmatched. The form is signed by the patient or legal guardian and attending physician authorizing the transfusion. It documents the crossmatching, receiving, and administering of the blood unit and records the patient's vital signs before and after the transfusion. Any reactions or issues during the transfusion are noted.

Uploaded by

GMCH Laboratory
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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BLOOD TRANSFUSION FORM

Name of Patient: Age/Sex:


Address: Ward:
ABO Type: Rh Type: Source of Blood:
Serial Number: Expiration Time: Expiration Date:

Type of Blood Component:

( ) Whole Blood ( ) Fresh Frozen Plasma ( ) Cryosupernate

( ) Packed Red Blood Cells ( ) Platelet Concentrate ( ) Others


( ) Washed Red Cells ( ) Cryoprecipitate Specify:
____________________________________________________________________________________
UNCROSSMATCHED

WAIVER: Because of the urgency need of the blood, within minutes, I hereby direct the laboratory
to release (type of blood/volume)

( ) Group O blood UNCROSSMATCHED


( ) ABO type ______ Rh type ______ UNCROSSMATCHED
( ) CROSSMATCHED Saline phase only
( ) CROSSMATCHED Saline and Albumin phase only
( ) BLOOD NOT SCREENED HIV Ab, HBsAg, HCV Ab, VDRL and Malaria
( ) Others: _______________

_______________________________ ______________________________
Patient’s or Legal Guardian’s Name w/ Attending Physician’s Printed Name w/
Date and Time Date and Time

CROSSMATCHED

( ) Saline Phase Only


( ) Saline and Albumin Phase Only
( ) Saline, Albumin, and Anti-human Globulin Phase

_______________________________ ______________________________
Patient’s or Legal Guardian’s Name w/ Attending Physician’s Printed Name w/
Date and Time Date and Time
____________________________________________________________________________________

Crossmatching done by: ______________________________ Date and time:____________________

Blood unit received by: _______________________________ Date and time:____________________

Appearance of unit checked by: ________________________ Date and time:____________________

Transfusion started by: _______________________________ Date and time:____________________

Vital signs Pre-transfusion:Temp ____________ RR ____________ PR ____________ BP ___________

Time transfusion completed/ discontinued: _______________________________________________

Vital signs Post-transfusion:Temp ____________RR ____________PR ____________BP ___________

REMARKS:

( ) Transfusion completed without immediate transfusion reaction noted.


( ) Transfusion stopped Date: ______________ Time: ______________
[ ] Fever [ ] Chills [ ] Nausea [ ] Vomiting [ ] Flushed [ ] Rashes [ ] Others: ______
( ) Transfusion resumed Date:______________ Time: ______________
( ) For transfusion reaction studies.

Prepared by:
______________________ ______________________
Laboratory Staff on Duty Nurse on Duty

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