Name: _____________________________

Pin No:_____________________________
Nationality:__________________________
Age:___________________Sex :________
Company: __________________________
Date of Admission: ___________________

BLOOD TRANSFUSION VITAL SIGNS SHEET

PATIENT DATA BLOOD PRODUCT DATA

SERIAL # :
PIN #: ___________________ UNIT: __________ ________________________________
COMPONENT :
PT. NAME: ________________________________ ____________________________
ABO/Rh :
SEX: ____________________ AGE: __________ _________________________________

ABO/Rh: __________________________________ REMARKS:

Special needs:
EXPIRATION DATE : _________ TIME: ______

Crossmatch Compatible? : ____________________ Specimen In-Date/Time :

Crossmatch Date/Time : ______________________ _____________________
Transfusion service comments: Antibody Screen : __________________________

Technician : _______________________________
(Name / ID #)
* * * * * TRANSFUSIONIST IDENTIFICATION CHECK * * * * *
Unit nurses have checked this slip with the bag labels, both the hospital and BB, wristband.
Transfusion started : ___________ _________ Transfusion completed : __________ __________
(Time) (Date) (Time) (Date)

Nurse : ___________________________________ Amount given : _____________________________

( Name / Signature / ID #)
Possible reaction ? YES NO
Doctor : __________________________________ If YES, use blood reaction form.
(Name / Signature / ID #)
Nurse : ____________________________________
(Name / Signature / ID #)
Comments :

*****VITAL SIGNS*****
TRANSFUSION ON GOING
Pre-Trans 5 min 10 min 15 min 30 min 1 hr 2 hrs 3 hrs Post-Trans
Temp.
Blood
Pressure
Pulse

2010-AOP-FM-030 Page 1 of 3
Respiratory Name: _____________________________
Pin No:_____________________________
Nationality:__________________________
Age:___________________Sex :________
Company: __________________________
Date of Admission: ___________________

LABORATORY DEPARTMENT
BLOOD TRANSFUSION REACTION INVESTIGATION RECORD
BLOOD COMPONENT UNIT NUMBER (S) : ROOM NO.:
Time & Date Time Apparent Quantity Remaining
Whole Blood F.F.P. Transfusion Begun Reaction Begun In Bag

Packed RBC’s Other

SYMPTOMS: BEFORE DURING AFTER VITAL SIGNS BEFORE AT START OF
TRANSFUSION TRANSFUSION
 Chill
 Back Pain Temperature
 Chest Pain
 Rash Pulse
 Shortness of Breath
 Fever Blood Pressure
DATE AND TIME REPORTED TO BLOOD BANK NURSE’S SIGNATURE & I.D. NO.:

TREATING DOCTOR NOTIFIED? YES NO ATTENDING DOCTOR’S SIGNATURE:

BLOOD BANK
IMMEDIATE INVESTIGATIONS:
1. Rechecked patient’s and donor’s identity, blood unit(s), and records and found no discrepancy.
Check by : __________________________________________________________ Date : ______________________
2. Visual inspection of patient serum: HEMOLYSIS JAUNDICE
PRE TRANSFUSION YES NO YES NO
POST TRANSFUSION YES NO YES NO
3. Direct anti-globulin test: PRE TRANSFUSION : _____________________________________________________
POST TRANSFUSION : ____________________________________________________
4. Bacterial studies done on container? YES NO
5. First voided specimen of urine Hemolysis? YES NO
CONFIRMATION OF ABO AND Rh TYPE INTERPRETATION GROUP & Rh
ANTI-SERUM
A B AB D
PRE-TRANSFUSION
RECIPIENT
POST-TRANSFUSION
DONOR SEGMENT
RECONFIRMATION OF CROSSMATCH
RECIPIENT SERUM REMARKS
DONOR RBC Enz 3.7° LISS COMPATIBLE
PRE-TRANFUSION SEGMENT

POST-TRANSFUSION SEGMENT

LAB. TECHNICIAN’S SIGNATURE: DATE:

CONCLUSION:

CONSULTANT’S SIGNATURE: DATE:

2010-AOP-FM-030 Page 2 of 3
2010-AOP-FM-030 Page 3 of 3