Blood Transfusion Record Page 2
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1
27689
05/12
SURNAME
HOSPITAL NO.
GIVEN NAME
B
T
LOOD
RANSFUSION
DOB
SEX
WARD
CONSULTANT
R
ECORD
Product
Time / Date Issued
Issued By
Affix label here
Checked by 1.
Product required: ........................................
2.
Date/Time Commenced
Date/Time Completed
Product
Time / Date Issued
Issued By
Affix label here
Checked by 1.
Product required: ........................................
2.
Date/Time Commenced
Date/Time Completed
Initial notification of Transfusion Related Reaction
All transfusion reactions must be reported on the NZ Blood Service form: Transfusion – related Adverse Reaction
Notification Form. This form also has guidance on the reverse side on how to proceed.
This Section is to allow for early notification to the Blood Bank and allow an identifiable record of events within
the patient record. This section may be omitted if the above form has been completed.
Please circle relevant symptoms listed below:
Febrile: Chills / Rigors / Flushing
Temperature rise:
oC
Allergic: Urticaria Isolated / Extensive
Non-urticarial rash
Anaphylaxis
Respiratory: Dyspnoea / Wheeze / Stridor / Pulmonary oedema / Cough / Hypoxaemia
Circulatory: Raised JVP / Hypertension / Arrhythmia / Hypotension
Pain: Chest / Loin / Abdominal / Infusion site / Other:
Restlessness / Anxiety
Red Urine: Yes / No / Unknown
Patient under anaesthesia: Yes / No
No symptoms
Chest X-ray changes:
Comments / any other signs & Symptoms
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