Transfusion Record Form
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1Transfusion Record
Date _____________________________
Patient ___________________________
Last Name ____________________________
Client #_________________
Wt: ___________ lbs / ____________ kg
DVM __________________________
Blood Type ________________________
Patient PCV/TP _________________
Donor PCV/TP _____________________
Cross Match
YES / NO
Previous Transfusion YES / NO
Previous Pregnancy YES / NO
Vomiting Prior Transfusion YES / NO
Diagnosis ____________________________________________
Transfusion Reason _______________________________
BLOOD PRODUCT (Circle)
DOSAGE
Plasma: 5 to 30ml/kg
Stored Whole Blood
Donor __________________________
Canine Whole Blood: 10ml/lb or 22ml/kg
Canine RBC: 5ml/lb or 11ml/kg or
Fresh Frozen Plasma
Unit Number ____________________
(
)
Blood (ml)= [BW(kg) x 90]x
desired PCV-recipient PCV
Frozen Plasma
Unit Size ________________________
PCV of donor
Feline:
Packed RBC
Type of filter used ________________
(
)
Blood (ml)= [BW(kg) x 70]x
desired PCV-recipient PCV
PCV of donor
Fresh Whole Blood
Start Time: __________ AM / PM T: ___________ HR: _____________ RR: ____________ MM:___________ CRT: ____________
15 min
30min
45min
60min
90min
120min
180min
210min
240min
Time
Rate
Temp
Pulse/HR
RR/Effort
MM/CRT
BP
Hives
Vomiting
Swelling/Itching
Volume Infused
Administration Rates: ________________________________________________________________________________
Start at 1ml/kg/hr for 15min, then 5ml/kg/hr for 15min, then a rate to deliver transfusion within 4 hours
Treatment Notes: ___________________________________________________________________________________
__________________________________________________________________________________________________
Medications Administered
Name and Strength
Dose
Route
Time / Tech Initials
10.2014
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