Platelet Rich Plasma/platelet Gel Record

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PLATELET RICH PLASMA/PLATELET GEL RECORD
Procedure Date_________________________
Patient Name_________________________________
Physician______________________________
Med. Record #________________________________
Anesthesia_____________________________
Age_______ Height______(inches) Weight______(lbs)
PRP Technician_________________________
Hgb/Hct/Plt. __________________________________
Procedure_______________________________
Allergies______________________________________
Facility___________________________ Previous Exposure to Bovine Thrombin?
Yes
No
Unknown
CHECKLIST
___Visual inspection of hardware/electrical
___Labels applied (patient & products)
___Operational modes working correctly
___Physician phlebotomy order in chart
___System components and backup available
___Thrombin & Calcium Chloride available
___Floating Shelf movement verified
___Syringe(s) Plunger movement verified
___Supplies availability verified
___Patient Consent Form completed and in chart
___Disposable(s) sterility intact, no defects noted
___Blood borne Pathogens/Sterile procedures followed
PROCESSING INFORMATION
Procedure: Start ______ End ______
Phlebotomy done by:____________________________
Venous blood drawn __________ml
Blood draw by:_________________________________
Draw Site_____________________
Product volume: ________ml PPP
________ml PRP
APPLICATIONS
Thrombin/Calcium Chloride: _______units Thrombin/_____ml Calcium Chloride
PRP vol. used__________ PRP application site(s)___________________________________________
PPP vol. used__________ PPP application site(s)___________________________________________
BONE GRAFT (
Applicable
Not Applicable)
Autograft
Allograft
Other______________________ Bone graft volume used _____cc
PRP vol. used for Bone Graft _____cc
Site bone graft applied__________________________________
CONCLUSIONS
___PRP Record Complete
___Disposal per biohazard policy
___Equipment cleaned/ready
___Assistance offered to MD and/or staff
EQUIPMENT/SUPPLIES
Lot Numbers
Exp. Date
Centrifuge used:
SmartPReP
____________
Not Applicable
Processing Kit Size:
20cc
60cc
120cc
____________
________
Applicator(s):
Liquid (x__)
Spray (x__)
____________
________
Anticoagulant: ACD-A
____________
________
Bovine Thrombin, 5000 unit vial
____________
________
10%Calcium Chloride, 10ml vial
____________
________
Other applicator tip: ______________________
____________
________
COMMENTS___________________________________________________________________________
_______________________________________________________________________________________
__________________________________________________________________________
Technician ___________________________
(Place patient sticker here)
Carolina Blood Management, Inc.

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