Form Doh 5209 - Blood Transfusion Record printable pdf download

NEW YORK STATE DEPARTMENT OF HEALTH

Bureau of Emergency Medical Services

Blood Transfusion Record

Blood and Tissue Resources Program

Patient Name (Print)

DOB

Patient ID

Date

Transferring Hospital Name

Receiving Hospital Name

PRETRANSPORT IDENTIFICATION:

Patient wristband ID compared with ALL blood component units at patient’s bedside with hospital staff

Products are packed in a validated transport container, with a pretransfusion blood specimen if available

Number and type of components agrees with physician’s orders

Patient has a dedicated venous access line with only blood and/or 0.9% NaCl running

Hospital Staff (MD or RN):

PRINT NAME

SIGNATURE

EMTCC/P:

PRINT NAME

SIGNATURE

Ambulance Service:

PRINT NAME

Vital signs, including patient temperature, are to be monitored every 10 minutes and recorded on PCR.

COMPONENTS TRANFUSED:

Adverse Reaction

Component

Unit ID Code

Unit ABO/Rh

Start Date/Time

End Date/Time

(Record details on PCR)

YES

If acute transfusion reaction is suspected: stop infusion, replace all tubing and maintain IV line with 0.9% NaCl. Contact Medical Control ASAP. Treat per protocol.

Remainder of unit and administration set must be given to receiving hospital staff. Do not initiate another unit unless advised to do so by Medical Control.

Medical Control Contacted:

PRINT NAME

SIGNATURE

Was a transfusion reaction suspected? Check correct box below.

No Transfusion Reaction NOT Suspected (Check off each item as completed.)

Discard empty blood bags & used administration sets as medical waste. Give the following to receiving hospital staff for delivery to blood bank:

Transport container(s)

Unused blood component(s)

Blood specimen(s) (if any)

Manifest/Packing slip

Copy of Blood Transfusion Record

Yes Transfusion Reaction Suspected (Check off each item as completed.)