Order For Therapeutic Phlebotomy
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1PHYSICIAN ORDERS
DIAGNOSIS:
DRUG SENSITIVITY:
Patient Identification
Order for Therapeutic Phlebotomy
1.
Diagnosis
Hereditary Hemochromatosis
Polycythemia vera
G
G
Porphyria
Secondary polycythemia
G
G
Hemochromatosis
Other _________________________________________
G
G
2. Does the patient have any significant co-morbidities or allergies that might affect collection
(eg: cardiac conditions) :
No
Yes (please describe below)
G
G
_________________________________________________________________________________________________
_________________________________________________________________________________________________
3.
Collect unit if *hematocrit is greater than: __________________________________________________________ %
*Based on spun hematocrit performed by Donor Services staff at time of visit
4.
ORDER:
a.)
Approximate volume to be collected: _________________ mLs whole blood
(Standard collection of whole blood unit is 450 mL. Maximum collection is no more than 500 mL).
b.)
How often (weekly, etc) _________________________________________
c.)
For how long before discontinuation (6 months, etc) ____________________
(NOTE: Standing orders must be renewed annually.)
Note to physician: By signing this order you are stating that, to the best of your knowledge, this patient should be able to tolerate
intravascular volume reduction of approximately 450 mL of whole blood without an excess risk to their baseline health status.
Date: ______________________ Time: ______________________
Physician’s Signature: _________________________________________________________________________________
Printed Name: ________________________________________________________________________________________
Department:__________________________________________ Phone Extension: _______________________________
Incomplete orders will not be accepted
Please note: Any new therapeutic phlebotomy services are limited to patients of Scott & White physicians.
Review of indication for phlebotomy performed by SWBC MD:
SWBC MD: __________________________________________
Date: ____________________
Comments: _______________________________________________________________________
_________________________________________________________________________________
Rev. 10/13
PR 10/29/13
MR FORM 1C
8/96
Distribution: White - Chart Copy
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