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Blood Request Form Adult

This document is a blood request form from Garcia Memorial Provincial Hospital in Bohol, Philippines. It requests blood products for a patient, including packed red blood cells, platelets, cryoprecipitate, and fresh frozen plasma. The form requires information on the patient's name, diagnosis, current blood counts and vitals, transfusion history, and the physician's indication for and requested type of each blood component according to established criteria. It also documents the screening process, number of units needed and provided, and obtains signatures for the requesting doctor and blood bank staff.

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94 views

Blood Request Form Adult

This document is a blood request form from Garcia Memorial Provincial Hospital in Bohol, Philippines. It requests blood products for a patient, including packed red blood cells, platelets, cryoprecipitate, and fresh frozen plasma. The form requires information on the patient's name, diagnosis, current blood counts and vitals, transfusion history, and the physician's indication for and requested type of each blood component according to established criteria. It also documents the screening process, number of units needed and provided, and obtains signatures for the requesting doctor and blood bank staff.

Uploaded by

sonnydominic
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Republic of the Philippines

PROVINCE OF BOHOL
Garcia Memorial Provincial Hospital
San Jose, Talibon, Bohol
Fax & Tel No.038-5155081
e-mail [email protected]
PHILHEALTH ACCREDITED HEALTHCARE PROVIDER

PHILIPPINE NATIONAL VOLUNTARY BLOOD SERVICES PROGRAM


(REGION) REGIONAL BLOOD SERICES NETWORK: NCR
(ZONE): _______________________________
BLOOD REQUEST FORM
(For ADULT)

Date: ________________ Hospital: ____________________

Name of Patient’s: _________________________________________________________ Age: ______ Sex_______


Surname First name Middle name
Amending Physician: ___________________________ Ward _________ Room #________ Hosp. # _________
Clinical Diagnosis: ______________________________________________________________________________
Patient’s Blood Type ___________________ Rh _____________
History of Previous Transfusion: When ____________________
Where ____________________
Type of Request ( ) ROUTINE ( ) STAT

Check Components Needed and Indication for Transfusion:

( ) Whole Blood (approximate volume 500 ml)


( ) WB – 1: Active bleeding with at least one of the following:
a. Loss of over 15% blood volume
b. Hb less than 9 g/dl
c. Blood pressure decrease over 20&, or less than 90 mm. Hg. systolic.
( ) WB – 2: Others: Please specify. ( This code will automatically trigger a review of your indication )

( ) Packed RBC (approximate volume 250 mL.)


( ) R – 1 Hb less than 8 gm/dl or Hct less than 24% (if not due to treatable cause)
( ) R – 2 Patients receiving general anesthesia if:
a. Preoperative Hb less than 8 g/dl or Hct less than 24%
b. Major bloodletting operation and Hb less than 10 g/dl or Hct less than 30%
c. Signs of hemodynamic instability or inadequate oxygen carrying capacity (symptomatic anemia)
( ) R – 3 Symptomatic anemia regardless or Hb level (dyspnea, syncope, postural hypotension, tachycardia, chest pains, TIA)
( ) R – 4 Hb less than 8 g/dl or Hct less than 24% with concomitant hemorrhage, COPD, CAD, hemoglobinopathy, sepsis
( ) R – 5 Others, Please specify. ( This code will automatically trigger a review of your indication )

( ) Washed RBC (Approximate volume 180 ml)


( ) WP – 1 History of previous severe allergic transfusion reactions or anaphylactiod reactions in immunocompromised
patients.
( ) WP – 2 Transfusion of group “O” blood during emergencies when the specific blood is not immediately available.
( ) WP – 3 Paroxysmal nocturnal hemoglobinuria
( ) WP – 4 Others, Please specify. ( This code will automatically trigger a review of your indication )

NOTE: Comments on RBC products:


1. Documents pre and post-transfusion Hb & Hct with 24 hrs.
2. Dose: Adults – give on a unit-to-unit basis.
Remember, 1 Unit may suffice to alleviate symptoms of anemia.
Infants: 10 ml/Kg. BW

( ) Platelets (approximate volume 50 ml)


( ) P – 1 Prophylactic administration with count < 20,000 and not due to TTP, ITP, HUS
( ) P – 2 Active bleeding with count < 50, 000
( ) P – 3 Plate count < 50, 000 and patient to undergo invasive procedure within 8 hrs.
( ) P – 4 Platelet count < 100, 000 if surgery in on critical area (e.g. eye, brain, etc.)
( ) P – 5 Massive transfusion with diffuse microvascular bleeding and no time to obtain platelet count
( ) P – 6 Others, Please specify. ( This code will automatically trigger a review of your indication ).
NOTE: Document platelet count before (within 8 hrs.) and after (within 1 hr.) transfusion.
Dose: 1 unit/10kg. BW with maximum of 8 units

( ) Cryoprecipitate (approximate volume 20 ml)

( ) C – 1 Significant hypofibrinogemia ( < 100 mg/dl)


( ) C – 2 Hemophilia A
( ) C – 3 Von Willerbrand’s disease or uremic bleeding with prolonged bleeding time.
( ) C – 4 Others, Please specify. ( This code will automatically trigger a review of your indication ).

( ) Fresh Frozen Plasma (approximate volume 200-250 ml)

( ) F – 1 PT or PTT > 1.5 times mid – normal range within 8 hrs. of transfusion (PT . 17 secs., PTT > 47 sacs. )
( ) F – 2 Specific factor deficiencies not treatable with cryoprecipitate
( ) F – 3 Reversal of Coumadin anticoagulation in patients who are bleeding and not treatable with vitamin K
( ) F – 4 Treatment of TTP
( ) F – 5 Clinical coagulopathy associated with:
a. Massive transfusion ( > 25 units of blood in 24 hrs.)
b. Late pregnancy termination or abruption placentae
( ) F – 6 Others, Please specify. ( This code will automatically trigger a review of your indication ).

No. of units needed: _______________________________ No. of Donors Provided: __________


Screened: __________
Unscreened: ___________

Type of Crossmatching

( ) Saline Phase only


( ) Saline, Albumin Phase
( ) Saline, Albumin, Globulin Phase

Others: ________________________________

Remarks: _____________________________________________________________________________________

-------------------------------------------------------
REQUESTING PHYSICIAN

Received by: ________________________________ Date/ Time _________________


Extracted by: ________________________________ Date/ Time _________________

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