BLOOD TRANSFUSION FORM

AGE / SEX: ____________ WARD : ___________

NAME: _______________________________
DATE: ________________
Blood TYPE: _______
PHYSICIAN: __________________________
Blood Unit Serial # : _______________________
Expiry Date : _____________________________
Blood Unit Received by :
Unit Blood Type : _________________________
____________________
__________
Issued By : _______________________________
(Name in Print / Signature)
(Date)
Component: ______________________________
Result of Compatible Testing :
Compatible with Patients serum
Appearance of unit checked by: _________________________
Date: ____________
Time: _______
Transfusion started by: ________________________________
Date: ____________
Time: _______
Transfusion completed by: _____________________________
Date: ____________
Time: _______
Transfusion set removed by: ____________________________
Date: ____________
Time: _______
Remarks:
( ) Transfusion completed without immediate transfusion reaction noted
( ) Transfusion stopped with transfusion reaction noted
( ) Fever ( ) Nausea ( ) Flushes ( ) Chills ( ) Vomiting ( ) Rashes ( ) Others
( ) For transfusion studies