Blood transfusion reports. These medical records from numerous detainees during March of 2003. The records are not separated to distinguish from one patient to another.
BLOOD OR BLOOD COMPONENT TRANSFUSION
MEDICAL RECORD
SECTION I -REQUISITION
TYPE OF REQUEST (Cheek ONLY if Red Blood REQUESTING PHYSICIAN (Print) COMPONENT REQUESTED (Check one)
Cell Products are requested.) 11b)(8)-2
RED BLOOD CELLS
TYPE AND SCREEN
DIAGNOSIS OR OPERATIVE PRO E
FRESH FROZEN PLASMA
CROSSMATCH
PLATELETS (Pool of units) -j : )
CRYOPRECIPITATE (Pool 0 f units) DATE REQUESTED
I have collected a blood specimen on the below named patient, verified the name and
ID No. of
n Rh IMMUNE GLOBULIN
the patient and verified the specim be label to be correct.
DATE AND HOUR REQUIRED
71 OTHER (Specify)
SIGNATURE OF VERIFIER SION REACTION (Specify) KNOWN ANTIBODY FORMATION/TRANSFU•VOLUME RETESTED (If applicable)
ML
4
DATE VERIFI
IF PATIENT IS FEMALE, IS THERE HISTORY
REMARKS: OF:
E GIVEN: TIME ItyRhIG TREA
HEMOLYTIC ASE OF NEWBORN? -
SECTION II - PRE-TRANSFUSION TESTING :b)(6)-2
PREVIOUS RECORD CHECK— TRANSFUSION NO.
TEST INTERPRETATION
UNII CR OSSMATCH RECORD 7,f," 0 RECORD
ANTIBODY SCREEN
TR
N 5 1:1 ., nroponmiNo T_S I
Si NAT xe)_2 —^ --
kt743410(Ali
NA,
RECIPIENTDONOR
CROSSMATCH NOT REQUIRED FOR THE COMPON N t-tt uerco 7-51\ A Ai-V577:-.
REMARKS:
ABO
Rh
SECTION III - RECORD OF TRANSFUSION
____42.9:11,1-110.2bLLLL
POST-TRANSFUSION DATAPRE -TRANSFUSION DATA
7 INTERRUPTED
TIME DATE COMP EED
AMOUNT GIVEN
INSPECTED AND ISSUED
L S'oc.)
RE CTION
n NONE riSUSPECTEDbp(
AT ON (Date) C5---.3
If reaction is suspected - IMMEDIATELY:
ID 1. Discontinue transfusion, treat shock if present, keep intravenous line open.
e Blood Component container label and this form and I 2. Notify Physician and Transfusion Service.
fi ation identifying the container with the intended recipient 3. Follow Transfusion Reaction Procedures.
tem by item, The recipient is the same person named on this Blood 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to
m
C• _ponent Transfusion Form and on the pati -t identification tag. the Blood Bank.
DESCRIPTION
15t
111 FEVER El PAIN
URTICARIA 111 CHILLD
11 OTHER
2nd VERIF (Sdrature)
1)56)-2
Fign DIFFICULTIES (Equipment, clots, etc.) AYAG -A 1-1
NO U YES (Specify)
PKETRANSFUSION
Xe)-2 OVE
TEMP. PULSE BP
fit
TIME DED
IS(TA.
DATE OF TRANSFUSION CD
b x
NAME - Last. first, middle; ran /tins te; hospital number and name of facnitY.)
PATIENT I ENTIFICATION • USE EMBOSSER (For typed or written entries glue: •
BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. 8-86) General Services Administration
Interagency Committee on Medical Records FIRMR (41CFR) 201-45405
518.122
MEDICAL RECORD COPY
MEDCOM -5767
DOD 12979
EDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I — REQUISITION
I ; PONENT REQUESTED (Check ane/ RED BLOOD CELLS FRESH FROZEN PLASMA TYPE OF KEDUES I (Check ONLY rIRed Blood Cell Products are requested.) TYPE AND SCREEN REQ(%15)(8)-2 " 1ve Ini.Ank !Print DIAGNOSIS OR OPERA-S.40 PROCEDURE
i0...CROSSMATCHPLATELETS (Pool of units)
CRYOPRECIPITATE (Pod of units)
DATE REQUESTED I have collected a blood specimen on the below
3
CA MAY
--1 Rh IMMUNE GLOBULIN named patient. verified the name and ID No. of DATE AND HOUR REQUIRED the patient and verified the specimen tube label to I] OTHER (Specify) be correct.
P6 A
SIGNATURE OF VERIFIERA/
OLUME REQUESTED (Ifenn/feeble/ KNOWN ANTIBODY FORM ON/TRANSFU-
SION REACTION (S fy
ML
.
reA414.))16 San') ot_e_
IF PATIENT IS FEMA (/E, IS THERE HISTORY DATE VERIFIED OF: EMARKS:
Lo•-f
RhIG TREATMENT DATE GIVEN' TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN'
SECTION II — PRE-TRANSFUSION TESTING
NIT NO. TRANSFUSION NO. PRE OIJS RECTO8.D CHEC
TEST INTER 'RETATION ANTIBODY SCREEN CROSSMATCH RECORD NO RECORD
El
361t3
-7
SIGNATURE OF PERSON P RFORMING TEST
PATIENT NO.
b)(6)-2
e)(1 LI-Ma ‘t
)0P1OR RECIPIENT
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REM ESTED { DATE
REMARKS:
ni30 ABO
ih FOS Rh pof7
SECTION HI — RECORD OF TRANSFUSION
,410(9 6 11
PRE -TRANSFUSION DATA POST-TRANSFUSI2N-DATr-
NS SUED BY ISimiata
AMOUNT GIVEN TIME DATE( rC5PL
-25-0 ML L REACTION
ElS NONE SUSPECTED
I I
1,T (Ho ur)
lfreaction is suspected — IMMEDIATELY:
IDENTIFICATION'
1. Discontinue transfusion, treat shock if present, keep intravenous line open. I have examined the Blood Component container label and this form and I 2. Notify Physician and Transfusion Service. find all information identifying the container with the intended recipient a Follow Transfusion Reaction Procedures. matches item by item. The recipient is the same person named on this Blood 4 Do NOT discard unit Return Blood Bag. Filter Set, and I.V. solutions to Component Transfusion Form and on the patient identification tag. the aTuid Bank.
DESCRIPTION
1st VER/FlER/SiarnaTaire)
b)(6)-2
URTICARIA CHILL FEVER n PAIN
1II fl
.
El OTHER
SbX 6)-2.
/6t" OTHER FFICULTI ES (Equipment, c .ts, etc.)
PRE- Lacp.NJ.-t. 0 El YES (Specif
TEMP. ei 1 ,2! PULSE 43 HP 1/2.7
DATE OF TRANSFUSION TIME STARTED
0.1
PATIENT IDENT !CATION - USE EMBOSSER (For typed or written entries gibe:
NAME - Las 'chile - rank/rate; hospital number and name of factittP.)
sys)-4
C
BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. 8-86) General Services Administration Interagency committee on Medical Recoras FIRMR (41CFR) 201-45.505
518-122
MEDICAL RECORD COPY
M EDCOM - 5768
DOD 12980
D ICA L RECORD
VIPONENT REQUESTED (Check one) RED BLOOD CELLS FRESH FROZEN PLASMA PLATELETS (Pool of.units) .
CRYOPRECIPITATE (poolo r -nib )
Rh IMMUNE GLOBULIN
OTHER (Specify)
.LUME REQUESTED (If applicable)
ML
.MARKS:
Cur( 00
JIT NO. ,
lik 41
4p I Li'Mn\i0 NOR
BO
(cL-1+1... 5 70C,
,T (Hour). OENTIFICATION
u'°4/f
TRANSFUSION NO.
1-t-,)
PATIENT NO.
RECIPIENT
ABO
Rh
PRE-TRANSFUSION DATA
ICIonnture.1
(ON (Date)
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION I YPE OF REQUEST (Check ONLY rtRed blood Cell Products are requested. )
TYPE AND SCREEN
litsCROSSMATCH
DATE REQUESTED
DATE AND HOUR REQUIRED
KNOWN ANTIBODY FORMATION/TRANSFU510N REACTION (Specify)
IF PATIENT IS FEMALE. IS THERE HISTORY OF:
RhIG TREATMENT?DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II PRE-TRANSFUSION TESTING TEST INTER 'RETATION ANTIBODY SCREEN CROSSMATCH
N/4
REQL)fbgrh: PHYSICIAN (Print)
DIAGNOSIS OR OPERA 1 IVE_tj•su...... DURE
I have collected a Mood specimen on the below named patient. verified rhe name and ID No. of
the patient and verified [he specimen tube label to be correct.
SIGNATURE OF VERIFIER
e"ev 1,0(A C
DATE VERIFIED
TIME VERIFIED
PREY NLCUK criECK:
RECORD NO RECORD
RSON PERFORMING TEST
b)(8}2
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED DATE
REMARKS:
SECTION III — RECORD OF TRANSFUSION
have examined the Blood Component container label and this form and I ind all information identifying the container with the intended recipient notches item by irem. The recjpient is the same Person named on this Blood :omponent Transfusion Form/And on the patient identification tag.
st VERI 7
b)(6)-2
RANSrUprupIU
TEMP. PULSE BP DATE OF TRAN1USION TIME STARTE
PATIENT I CIN4IF A ON - USE EMBOSSED (For typed or written entries give: NAME - Last, first, mill • rank/rale; hospital number and name of facility.)
b)(8)-4
MEDCOM - 5769
POST-TRANSFUSION DATA AMOUNT GIVEN TIME DATE eptitPLETED IN TERAWTED
ML OS— c2Ph"14,,sL3
REACTION NONE . SUSPECTED
If reaction is suspected — IMMEDIATELY:
1.
Discontinue transfusion, treat shock if present, keep intravenous line open.
2.
Notify Physician and Transfusion Service.
3 Follow Transfusion Reaction Procedures.
4, Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to
the ETEiTid Bank. DESCRIPTION
PAIN
URTICARIA riCHILL [i] FEVER
E OTHER
OT R DIFFICULTIES (Equipment, clots, etc.)
No
• te)-2
riYES (specify)
01
BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. 3.136) General services Administration
Interagency Committee on Medical Records
FIRMR (41CFR) 201.45,505
518.12 2
MEDICAL RECORD COPY
DOD 12981
BLOOD OR BLOOD COMPONENT TRANSFUSION
EDICAL RECORD
SECTION I — REQUISITION TYPE OF REQUEST (Check ONLY if Bed Blood 1REQUESTING PHYSICIAN (Print)
iMPONENT REQUESTED (Check one)
Cell Products are requested.)
IT RED BLOOD CELLS
I I TYPE AND SCREEN
DIAGNOSIS OR OPERATIVE PROCEDURE
FRESH FROZEN PLASMA
EA CROSSMATCH
I
PLATELETS (Pool of.units)
CRYOPRECIPITATE (Pool of units) DATE REQUESTED I have collected a blood specimen on the below
named patient, verified the name and ID No. of
Rh IMMUNE GLOBULIN OqWIAti ° g
DATE AND HOUR REQ1,,/,,I RED the
patient and verified the specimen tube label to pe correct.
OTHER (Specify)
Pr('
SIGNATURE OF VERIFIER
KNOWN ANTIBODY FORMATION(TRANSFU-
)LUME REQUESTED (If applicable ) SION REACTION (Specify)
1
ML
retitoils Sc? *up le,-
IF PATIENT IS FEMALE, IS THERE HISTORY DATE VERIFIED
EMARKS:
P
OF
C (/(-3 i ik)
RhIG TREATMENT? DATE GIVEN: TIME VERIFIED
__,,
...--11 —
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II — PRE.TRANSFUSION TESTING
PREY US RECO D CHECK:
NIT NO. TRANSFUSION NO. TEST INTERPRETATION
ANTIBODY SCREEN CROSSMATCH RECOR NO RECORD
ri Jnr roc ncocrmi PFPFCIF MING TEST
PATIENT NO. 1(13)(8)-2
3 ptP
N/A
RECIPIENT
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REM ESTED1I-u-k I c REMARKS:
ABO
,B0
Rhth
SECTION III — RECORD OF TRANSFUSION
LbX
POST-TR ANSFUSIrtrAT
PRE-TRANSFUSION DATA
MPLETED..9 INTERRUPTED
AMOUNT OfFN TIME DATE
Y Signature
14(8)-2 ML
REACTION
NONE SUSPECTED
ON (Date)
7), 4
T (Hour)F"
If reaction is suspected — IMMEDIATELY:
DENTIFICAT ON' open.
1. Discontinue transfusion, treat shock if present, keep intravenous line
have examined the Blood Component container label and this form and I 2. Notify Physician and Transfusion Service.
iind all information identifying the container the intended recipient
3, Follow Transfusion Reaction Procedures. person named on this Blood 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to
-natches item by item. The recipient is the sa
component Transfusion or and on the p nt identification the STO-Ed Bank,
DESCRIPTION
riFEVER PAINEl URTICARIA CHILL
111 OTHER
H R DIFFICULTIES (Equipment, clots, etc.)
NO Y S•ecf)59 .
PRE-TRAKSF1.151,0N
GC/ SIG
TEMP. PULSE
BP'11 ' 11 0
DATE OF TRANSFUS. TIME STARTEAD
6
PATIENT IDEN IFICATION USE EMBOSSER (For typed or written entries glue: SEX
NAME Lost, first, middle; rank/rate; hospital number and name of facility.)
BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. 8-86)
General Services Administration
Interagency Committee on mealcal Records FIRMR (41CFR) 201-45.505 518-122
MEDICAL RECORD COPY MEDCOM -5770
DOD 12982
DICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I — REQUISITION
TYPE OF REQUEST (Chock ONLY if Red Blood REQUESTING PHYSICIAN (Print) Cell Products are requested.)
MPONENT REQUESTED (Check one)
RED BLOOD CELLS y TYPE AND SCREEN
FRESH FROZEN PLASMA DIAGNOSIS OR OPERATIVE PROCEDURE
CROSSMATCH
PLATELETS (Poo) of_.units)
CRYOPRECIPITATE (Pool of.units) E ED
OATEI,EM J
I have collected a blood specimen on the below Rh IMMUNE GLOBULIN () named patient, verified the name and ID No. of DATE ND HOUR REQUIRED the patient and verified the specimen tube label to be correct.
OTHER (Specify) .
Nsa?
KNOWN ANTIBODY FORMATION/TRANSFU -SIGNATURE OF VERIFIER
)LunnE REQUESTED (If applicable ) SION REACTION (Specify)
ML
-
Rek,/ tokA6 c,(11
I F PATIENT is FEMALE, IS THERE HISTORY DATE VERIFIED
=mAR'CLb -r OF:
Rh IC TREATMENT? DATE GIVEN:
TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN? —
SECTION II — PRE-TRANSFUSION TESTING
PRE IOUS R CHECK:
NO RANSFUSION NO. TEST INTERPRETATION ANTIBODY SCREEN ICROSSMATCH RECORD NO RECORD
7/r1 Ogg.
CR:NATURE OF PERSON PERFORMING TEST
PATIENT NO.
bX8).2
OMP .
:p )4 t4.11\/
ONOR RECipIEN 1
-I CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQU STED DATE
A
ABO -REMARKS:
BO
Rh
POs Fibs
SECTION III — RECOF D OF TRANSFUSION
LIQ&131_4-3q
OST-TRANSFUSION DATA
PRE-TRANSFUSION DATA
AMUUN I UIVEN TIME— DATE COMPETED INTERRUPTED
sIspFrTE0 AND ISSUED BY (Signature)
ML 1 it OC/45. 0:1 /17,1‘, REACTI ON ..1 1.-NONE pi SUSPECTED
.
mate) °t Ma—, .93
If reaction is suspected — IMMEDIATELY: 4' 2 6, /du
DEN TIFICATION LI
1. Discontinue transfusion, treat shock if present, keep intravenous line open.
have examined the Blood Component container label and this form and I 2. Notify Physician and Transfusion Service. Ind all information identifying the container with the intended redolent 3. Follow Transfusion Reaction Procedures. natches item by item. The recipient is the same person named on this Blood 4. Do NOT discard unit. Return Blood Bag, Filter set and I.V. solutions to
ent Trans fuf.sion Form patient identification tag. the Blood Bank.
DESCRIPTION
URTICARIA 111 CHILL Fi FEVER . PAIN
and on the OTHER
11111111111111
DX6)-2
OTHER DIFFICULTIES (Equipment, clots, etc.)
YES (Specify)
b)(3)-2 ^'^TING ABOVE
TEMP. PULSE BP
DATE OF TRANSFUSION TIMES TAATED
5r
g PlAY 63 i 5
ti,ATIE NT IDENTIFICATION - USE EMBOSSER Tor hip,gljgr written entries give:
WARD
NAME -Last, first, middle; rank/rate: hospital number and name of facility.)
:14(6)-4 e61
BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. 8-861 General Services Administration Interagency Committee on Medical Recoras FIRMR (41CFR) 201-45.505
518-122
MEDICAL RECORD COPY
MEDCOM -5771
DOD 12983
BLOOD OR BLOOD COMPONENT TRANSFUSION
EDICAL RECORD
SECTION I - REQUISITION
IMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood REQUESTING PHYSICIAN (Print)
Cell Products are requested.) (bxe)-2
RED BLOOD CELLS n TYPE AND SCREEN
FRESH FROZEN PLASMA -u t. t.r b b R-O-Rk-R-A-I-I4E PROCEDURE
154 CROSSMATCHPLATELETS (Pool of units)
rc7v1
CRYOPRECIPITATE (Pool of units)
DATE REQUESTER • -7
I have collected a blood specimen on the below
0qA4a..05
Rh IMMUNE GLOBULIN . . -- '" named patient. verified the name and ID No. of
r •-.1
DATE AND HOUR REQ I D the patient and verified the specimen tube label to be correct.
OTHER (Specify) . ^ C
L
KNOWN ANTIBODY FORMATION/TRANSFU-SIGNATURE OF VERIFIER SION REACTION (Spec'.1DLuME REQUESTE D (If applicable)
i4.4 ft-M L
/ V /9 r in4 0 tit5-./1/Pte"
byATIENT IS F MALE, IS THERE HISTORY DATE VERIFIED
_MARKS:
A
q-; a 3
RhIG TREATMEP 7 GIVEN TIME VERIFIED ! _.../
HEMOLYTIC DISEAS OF NEVVBORN 7 — '.)-- j
l Y.
SECTION II - PRE-TRANSFUSION TESTING PRE OU CORD CHECK;
TRANSFUSION NO..
T TEST INTERPRETATION
ra
LIZ 1-ANTIBODY SCREEN CROSSMATCH RF-ORD . NO RECORD
cir.NATUR_E 9F PERSON PERFORMING IST
PATIENT Nb. etvp
yp
N/A-/13)
ONOk RE CI PI ENT
pue, ep
DATE
CROSSMATCH NOT REOUIRE-i--OR THE COMPONENT REQUESTED
BO CBO n/T !2 REMARKS:
"
h PQ-s-
2C4 SECTION III - RECORD OF TRANSFUSION
,S C )pr:3--1-1
POST.TRANSFUSION DATA AMOUNT G) VEN 'TIME DATE COMPLETED I R RUPTED
PR - RANSFUSION DATA
••ISPECTED AND ISSUED BY (Signature)
vi s--9 )71
b)(6)-2 I LOA. I
ML
REACTIO,
USR T D
.T (Ho ( o 7 ref ;
5
If reactlo is sus cted - I MM
DENT CATI ON'
1. Discontinue transfusion, tre t shock if present, keep intravenous line open. have examined the Blood Component container label and this form and I 2. Notify Physician and Transfusion Service. Ind all information identifying the container with the intended recipient a Follow Transfusion Reaction Procedures.
natches tern by item. The recipient is the same person named on this Blood 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to :omponent Transfusion Form and on the patient identification tag. the BIOTA Bank.
b) )-2 OESCRI PTION
St VERI'
. PAIN
. URTICARIA.. CHILL . FEVER
/
P)(6)-2 . OTHER -
1
—11"10 CCGA/Cr11 --uTHE "fr-FICULTIES (Equipment, riots, etc.)
NO . YES (Specify)
srutvrr
cle-gn¦ A -ri aF nF PERSON NOTING ABOVE
TEMP. PULSE / 1-7-BR 9 171/ r DATE OF TRANSFUSION 'TIME STARTED
2 -2-O
C)3aTieNT I DENT! !CATION -WARE VAMS -Last, first, middle; rant:irate; ()spite num 3%;r1,11: WrigifiVes
(b)(6)-4 BLOOD OR B.I.D_OLD filqMPONENT TRANSFUSION
STANDARD FORM 51S (REV. 8-86) General Services Administration Interagency Committee on Medical Records' FIRMR (41CFR) 201-45.505 510-122
MEDICAL RECORD COPY
MEDCOM - 5772
DOD 12984
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one) TVPE OF REQUEST (Check ONLY if Red Blood RE b)(8)-2 Cell Products are requested.)
RED BLOOD CELLS
ILS
111 TYPE AND SCREEN
{1 FRESH FROZEN PLASMA INA NUS'S OR OPERA I ivt rilocEou RE
**I CROSSMATCH
111 PLATELETS (Pool or units) El CRYOPRECIPITATE (Pool of .units)
DATE REQUESTED I have collected a blood specimen on the below
/ _ P?
• //CY.
Rh IMMUNE GLOBULIN V' L. named patient, verified the name and ID NO. of DATE AND HOUR RCQUI RED the patient and verified the specimen tube label toEl OTHER (Specify) .
be correct
A-SA-1
ITRANSFU- SIGATURE OF VERIFIER SION REACTION (Specify-)
VOLUME REQUE5 IU fir applicable) KNO‘Alhp'ANTIBODY FOR MATION N
i....
LA ML `& VAA 3:5(4411 k
A / 1 .
TFFATIENtit FEMALE, IS THERE HISTORY DATE VERIFIED
REMARKS: RhIG TREATMENT? DATE GIVEN TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II -PRE-TRANSFUSION TESTING
PREV OUS P ORD CHECK:
TRANSFUSION NO.
TEST INTERPRETATION ANTIBODY SCREEN CROSSMATCH RECOR51 0 NO RECORD
"r nrocroo PFRFC/RMING TEST
PATIENT b)(6)-2
Co
PIA
RECIPIENTDONOR
CROSSMATCH NO COMPONENT REQU ESTED Yu
ABO REMARKS:
ABO
Rh
roc Rh
SECTION III -RECORD OF TRANSFUSION
POST-TRANSFUSION DATA AMOUNT CI "EN 'TIME DATE -C....SeIPLETE
PRE-TAANSFUSION DATA
IN TE RR U PTED
INSPECTED-AND-ISSUED BY (Signature)
ML eteCT--964PL4--
v
REACTION
ONE [ SUSPECTED
AT (Hour) 0 N (Date) FJ ('
--I C'?
If reaI tion Aptdteki -Zelcb :
IDENTIFICATION' 1. Discontinue transfusion, treat shock if present, keep intravenous line open.
I have examined the Blood Component container label and 'this form and I 2. Notify Physician and Transfusion Service.
find all information identifying the container with the intended recipient 3. Follow Transfusion Reaction Procedures.
matches ite n by item. The recipient is the same person named on this Blood 4, Do NOT discard unit. Return Blood Bag. Filter Set, and I.V. solutions to
Component -br) (,-63_,2,d.,k¦ on Form and on the patient idehtifOtion lag. the Blood Bank. 1st VERIF4 (DESCRIPTION
URTICARIA . CHILL ri FEVER 111 PAIN
2nd VERIF n OTHER
b)(6)-
OTHER F I CULTIES (Equipment, clots. etc.)
.O YES (Specify)
fl
• • • • • OVE
TEMP. PULSE I 6 Bp pi-e (6)-2 DATE Oi-TRANSFUSION TIME STARTED
(4
4-`1 6 ) 3 7
PATIENT • USE EMBOSSER Tor types or written en tries giu 'WARD
Nr AME . Lost, first, middle; rank/rate: hospital number and name of facility.)
I Tc U
BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (Rev. 8-861 General Services Administration
m encz(committeec
Fm .4 Records FIRMR 518-122
MEDICAL RECORD COPY MEDCOM - 5773
DOD 12985
-I.
•
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I — REQUISITION
o /Pr nt).
TYPE OF REQUEST (Check ONLY if Red Blood IREAUESTI Cell Producla are requested.)
COMPONENT REQUESTED (Check one)
[RED BLOOD CELLS
Ili TYPE AND SCREEN
j
11 F RESH FROZEN PLASMA DISI'., — ROCEDURE
EILCROSSMATCH
EI PLATELETS (Pool of .units)
I CyStu
C RYOPRECIPITATE (Pool of units)
REQUESTED I hove collected a blood specimen on the below
DATE REQUESTED
Rh IMMUNE GLOBULIN Inamed patient, verified the name and ID NO. of DATE AND EITUIRED the patient and verified the specimen rube label to be correct.
. 9 A
. OTHER (Specify) .
KNOWN ANTIBODY FORMATION/TRANSFU-SIGNATURE OF VERIFIER SION RE.4.(.."ION (Specify)
AVk-\, ML
VOLUME REQUESTED (If applicable)
4-"N 4071,V,1‹
REMARKS: —IF PATIENT PS FEVALE, IS THERE H ISTORY DATE VERIFIED rce
OF:
RhIG TREAhli+ATE GIVEN" TIME VERIFIED
HEM0LYTICDISEASE OF NEWBORN? —
SECTION II — PRE-TRANSFUSION TESTING TPREVICIUS REC CHECK:UNIT NO. 'TRANSFUSION NO.
TEST INTERPRETATION ANTIBODY SCREEN CROSSMATCH [54_ RECORD )pi----E1 NO RECORD
I./G.530bl PATIENT NO.
SlrajlifURE OF ERSON PERFORMING TEST
2s
0 RECIPIENT
E PU ESTE°
LJ /- I 11.1 ktsji,\
CROSSMATCH NOT REQUIRED FOR THE COMPCII ENTT
ABO fol A REMARKS;
Rh Rh
p Os
)
c) =)
SECTION III — RECORD OF TRANSFUSION POST-TRANSFUSI N DATA
PRE-TRANSFUSION DATA
AMOUNT GIV,EN I TIME TE OMPLETED INTERRUPTED
r
)(03)-2
"j•-•"1. MI_ I REACT ION NONE SUSPECTED
I-kr(Hour/ I@IAV (Date) ies.06sitt — IM4EDIATELY:
IDENTIFICATION'
I (, ti e
ns4sion. treat shock if present. keep intravenous line open. I have examined the Blood Component container label and this form and I 2. Notify Physician and Transfusion Service. find all information identifying the container with the intendedi9sinimn_t 3. Follow Transfusion Reaction Procedures.
matches item by item. The recipient is the same person named °n th is Blom, 4. Do NOT discard unit Return Blood Bag, Filter Set, and I.V. sold tionS to
Component TransfOffLlorm_and on the patient ides ifira. n tag. the IFOTtd Bank.
DESCRIPTION
1st VERIFIER
URTICARIA El CHILL riFEVER PAIN
in OTHER
Equipment, clots, etc.)
0 YES (Specify )
PRE-T ' SeN
—NOTING v RrINIF
TEMP. PULSE /
ERSCIN—
5
Rp_7 -si sc
DATE OF TRANSFUSION TIME STARTED
PAT ioEN IFICATioN . MBOSSER (For typed or written en es
NA ME Last, first, middle: rank/rate; hospital number and name of facility.)
t\ bic
BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 ( REV. 8 -85) General services AdminIstratiOn
Interagency Committee on Medical Records FIRMR (41CFR) 201 -45.505
518.122
MEDCOM - 5774
DOD 12986
*U.S.GP0:1993.0.337-272/80075
•
lb S
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I — REQUISITION
OF -0 I oo. REQUES N _Glad CFAN Print)
COMPONENT REQUESTED (Check one) ' ' e • ' if Red :
q
Cell Products are requested.) b)(0)-2
l_ RED BLOOD CELLS ---
(
TYPE AND SCREEN
n FRESH FROZEN PLASMA D i A GINZA i s ( ATIVE PROCEDU RE
VNCROSSMATCHPLATELETS (Pool of units)
c1— 5
r
. CRYOPRECIPITATE (Pool o f units)
DATE REQUESTED I have collected a blood specimen on the below Rh IMMUNE GLOBULIN named patient, verified the name and ID No. of
°) YIN? ei DATE AND REQUIRED the patient and verified the specimen tube label to
OTHER (Specify) Pk-n correct.
VOLUME REQUESTED (If applicable) KNOWN .41 4-.' RMATION/TRANSFU-SIGMTURE OF VERIFIER
SION REAC (SP Y)
JAW\ ML
yfriA)-ADIA4
REMARKS: IF PATIEN IS FEMALE, IS THERE HISTORY DAT VERIFIED
OF:
RhIG TREA T? D E GIVEN• TIME VERIFIED
HEMOLYTIC ISEA NEWBORN?
SECTION II — PRE-TRANSFUSION TESTING
PREVIOUkRECORD CHECK:1...1NC NO. TRANSFUSION NO.
TEST INTERPRETATION
Y¦
ANTIBODY SCREEN CROSSMATCH REEORD NO RECORD
I I
* -)•?,!
PATIENT NO. SI NA/T.0 RE,OF PERSON PERFORMING TEST
b)(13)-2
),() \.1
D NOR RECIPIENT
CROSSMATCH
REMARKS:
0
ABO
Rh 0_3 Rh
SECTION III — RECORD OF TRANSFUSION
I-) S Njk
PRE-TRANSFUSION DATA POST-TRANSFUSION DATA INSPECTED AND ISSUED BY Si .nature) AMOUNT tilVEN TIME DATE COM INTERRUPTED
px6)-2 72,50, 400 ML IDS .1\.Mr
REACTION
N ONE El SUSPECTED
AT (Hour) D 9 Q ON (Date)
IDENTIFICATION' If reaction is suspected — IMMEDIATELY:
1. Discontinue transfusion, treat shock if present. keep intravenous line open. I have examined the Blood Component container label and this form and I 2. Notify Physician and Transfusion Service. find all information identifying the container with the intended recipient 3. Follow Transfusion Reaction Procedures. matches item by item. The recipient is the same person named on this Blood 4. Do NOT discard unit. Return Blood Bag, Filter Set and I.V. solutions to Component Transfusion Form and on the patient identification rag. the 1706d Bank.
1st VERIFIER (Signature) DESCRIPTION
URTICARIA I I C HILL FEVER [1] PAIN
[ I OTHER
QTFtER DIFFICULTIES (Equipment, clots, etc.)
riY
NO ES (Specify) .
largi SIG ATURE OF PERSON NOTING ABOVE
TEMP. CA BP i 1.1
kb)(6)-2
DATE OF TRANSFUSION TIME STARTED
lLa %. F.11.--)
Mpim .T.3 QC13
PATIENT IDENTIFICATION • USE EMBOSSER (Por typed Or written entries glee' sp nA IWARD ,
NAME. Last, first, middle; rank/rate; hospital number an name of facility.)
I \\ \
BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. 8.86) General Services Administration Interagency Committee on Medical Records FIRMR (41CFR) 201-45.505
MEDCOM - 5775
518-122
DOD 12987
*U.S.GP0:1993.0.337-272/80075
"rrs.1a.. ,' 6./ aoF
MEDICAL RECORD
COMPONENT REQUESTED (Check one)
1911117I, RED BLOOD CELLS
. FRESH FROZEN PLASMA
. PLATELETS (Pool of-units) CRYOPRECIPITATE (Pool of.units)
Rh IMMUNE GLOBULIN
.
OTHER (Specify) VOLUME REQUESTED (If applicable))
l ,(A.,;J\. ML
REMARKS:. ^
0 LO'ri i'j
TRANSFUSION NO.
PATIENT NO.
RECIPIENT
ABO ABO
v4 6
Rh Rh
Pos Pis
110
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I -REQUISITION
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
7 TYPE AND SCREEN
CROSSMATCH
EGUESTE
DATER
6 COL)
DATE AND HOUR REQUIRED
.O. fri441 ,,-1))
KNO N ANTIBODY t'ORMATION/TRANSFU-SION E CTION (Specify)
A
A
IF PATTEN I EMALE, IS THERE HISTORY OF:
RhIG TRE GIVEN:
er-
HEMOLYTI D SASE
ASE OF NEWBORN?
SECTION II -CAE-TRANSFUSION TESTING
TEST INTERPRETATION
ANTIBODY SCREEN CROSSMATCH RFoliFsTING pHYSICIAN (Print)
(b)(6)-2
DIANOSIS OR OPERATIVE PROCEDURE
G4.5 60(..)
I have collected a blood specimen on the below named patient, verified the name and ID No of the patient and verified the specimen tube label to be correct
SIGNATURE OF VERIFIER
A I
11/11/„4:.4 Au VI
DATE VERIFIED
TIME VERIFIED
PREVIOUS RECORD CHECK:
RECORD [11 NO RECORD
X8)-2
ri io ng PF-PC(1N PFRFDRMING TE
/I 1-2
JCROSSMATCH NOT RE RED R THE COMPONENT REOUESTEDJ:OA1 REMARKS:
• „
, PRE-TRAN SFUSION DATA
I NSP Lure)
AT (Ho ur) ON (Date) 1/ "4
IDENTIFICATION
I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and on the patient identifibation tag.
miey2
HatiitsES,
it0(6)-2
PRE
TEMP. 92-, PULSE BP DATE -7, S I • 1 TIME
103o
SECTION III - RECORD OF TRANSFUSION
CAN* 741-7-5 72-tig)
PA4ENT 10E TIFICAl ION - USE EMBOSSER (For typed or written en tries NAME • Last. first, middle; ranh/rate; hospital number and name of facility.)
(6)(8).4
MEDCOM - 5776
POST-TRANSFUSION DATA
AMOUNT GIVEN TIME DATE COMPLETED, INTERRUPTED
35-0 ‘"taL) ML 1,33c, II NAY c?,_.3
REACTION NONE 111 SUSPECTED
If reaction 15 suspected IMMEDIATELY
1. Discontinue.tcansfosico, tre_at shock if, resent, keep intravenous line open
2, Notify Physician and Transfusion Bervite.
3.
Follow Transfusion Reaction Procedures.
4.
Do NOT discard unit Return Blood Bag. Filter Set, and I.V. solutions to
the STFEld Bank. DESCRIPTION
URTICARIA . CHILL . FEVER PAIN
111
. OTHER
ptOTHDIFFICULTIES (Equipment, clots. etc.)
NO .
rtn-ri IQ rw PF
ru
)(8)-2
YES (Specify)
NOTING ABOVE
WARD 6-e 2_
BLOOD OR BLOOD COMPONENT TRANSFUSION
STANDARD FORM 518 (REV. 8-86)
General Services Administration
Interagency committee on Medical Records
Fl RMR (41CFR) 201-45.505
518-122
DOD 12988
0
NISff 7540-00-(534-41.
MEDICAL RECORD BLOOD CR BLOOD COMPONENT TRANSFUSION
SECTION I -REQUISITION
COMPONENT REQUESTED (Check we,: TYPE CF REQUEST (Check ONLY if Red Blond Cell REQUESTING PHYSICIAN (Print) Products are requested.) 1(13)(e)-2 RED BLOOD CELLS
.1,:tiiTYPE AND SCREEN
FRESH FROZEN PLASMA DIAGNOSIS CR OPERATIVE PROCEDURE
'CROSSMATCH
.._
PLATELETS (Pool of units)
14... Ct),) A.);1.1-214.e -k) L
CRYOPRECIPITATE (Pool of.units)
DATE REQUESTED
I have collected a Mood scinien on Inc Rh IMMUNE GLOBULIN
named patient. verified the name and IC of it patient and verified the specimen tube label to t
/ 0 3 No.
RDATE AND HOURRE [..] OTHER (Specify) . b)(6)-2
VOLUME REQUESTED (If applicable) KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
ML
IF PATIENT IS FEMALE. IS THERE HISTORY OF:
REMARKS'
i
RhIG TREATMENT? DATE GIVEN: /144 ety TINE VERIFIED
HEMOLYTIC DISEASE CF NEWBORN?
r.r7 c7e.??c,
SECTION II - PRE-TRANSFUSION TESTING
UNIT NO. 27) 04 TRANSFUSION NO. TEST INTERPRETATION PREVIOUS RECORD CHECK.
.7 ei
ANTIBODY SCREEN CROSSMATCH N. RECORD wiREcoRD_____
Li23
PATIENT NO. lIA RERSOLLEEBE,ORMING TEST
b)(6)-2
INA iA.C urlp
J`/f4.
DONOR , :IS PO46
A
sraro
CROSSMATCH NOT REQUIRED FOR THE COMPONENT Ocior-DATE ILI riiqu-5
ABO REMARKS:
Rh fbi
El 6 3
POST-TR" TIME/DAT COMPLET /INTERRUPTED
PRE-TRANSFUSION DATA
re)
ML
C
REA•ON T PERATURE PUL E BL( 0 PRESSUR
(Hour) ON (Date) NE [11 SUSPECTED '
IDENTIFICATION If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container label and this form information identifying the container with the intended recipient match and I find all item by item. 1. Discontinue transfusion, treat shock if present, keep intravenous line open 2. Notify Physician and Transfusion Service.
The recipient is the same person named Blood on.T 'on Form and 3. Follow TransfuSion Reaction Procedures.
on tl rfatient identificetionJorN 4. Do NOT discard unit. Return Blood Bag. Filler Set. arid I.V. solutions to the Blood Ban
ME0-2 DESCRIPTION OF REACTION
1=1 URTICARIA n CHILL . FEVER . PAIN
Li OTHER (Specify)
1,56)-2
1A__I-1 ,(sys) OTHER DIFFICULTIES (Equip2,14,-s.142ks, etc.)
ron,.1-1 vr, r-onarw. Ft .1
PRE-TRANSFAS(1.10; ,i ....Th ,b)(6)-2
-I. L. ,,I,,,,
TEMP. I PULSE CC,.IBP (r3tC1
DATE OF TRANSFUSION TIME STARTED 9
PATIEIt T IDENTIFIC..,‘11 —USE EMBOSSER (For typed or written entries give: Name—Last first le; grade; rank; spital or medical facility)
z
BLOOD OR BLOOD COMPONENT TRANSFUSION
MEDCOM -5777
AAcHiral Parnrri
DOD 12989
L
NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
TYPE OF REQUEST (Check ONLY if Red Blood Cell REQUESTING PHYSICIAN (PrIn!) b)(6)-2COMPONENT AEQUESTED (CheCK one!
Products are requested.)
RED BLOOD CELLS
L
TYPE AND SCREEN
O FRESH FROZEN PLASMA DIAGNOSIS CR OPERATIVE PROCEDURE
CSZ CROSSMATCH
PLATELETS (Pool of .Links)
• CRYCPRECIRTATE (Pool d units) DATE REQUESTED
I have collected a blood specimen on rlie
-named patient, verified the name and ID No. of Lie
• Rh IMMUNE GLOBULIN
patient and verified the specime n tube to beI ! I
DATE AND HOUR nclbIREO
correct.
D OTHER (Specify)
PI-P •
VOLUME REQUESTED (lf applicable) KNOWN ANTIBODY FORMATION/TRANSFUSION
REACTION (Specify)
ML
IF PATIENT IS FEMALE. IS THERE HISTORY Cf:
REMARKS:
RhIG TREATMENT? CATE GIVEN:
TIME VERIFIED HEMOLYTIC DISEASE Of NEWBORN? 1.../.I b)(6)-2
1.../ '
irliTUSION TESTING
----NetliP•11.111 h
PREVIOUS RECORD CHECK:
UNIT NO. TRANSFUSION NO. TEST INTEgPRETATION
ANTIBODY SCREEN CROSSMATCH &RECORD NO RECORD
1 16Di/23 1-123
'" PrP`"I'l ""'rnRMING TEST /qfiqy 0
PATIENT NO.
1A/A ( el( DONOR RECIPIENT IS 37' Arq, CROSSMATCH NOT REQUIRED FCR THE COMPONENT REQUES DATE^q c3 . ABO REMARKS:
N30 A A6
Rh Rh
fW F t)
SECTION III - RECORD CF TRANSFUSION
_LEH PX
POSTTRANSFUSION DATA GIVEN I TIME/DATE COMPLETED/INTERRUPTED PRE-TRANSFUSION DATA
INSPECTED AND ISSUED BY (Signature)
bX6)-2
AMOUNT vjl ML 11;6N . TEXERATURE I PULSE f3r?Oa.1,
-'RESSURE
AT (Hour).V 1 (7) C 5 ON (Date).! hi-i
IDENTIFICATION If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container label and this form and I find all 1. Discontinue transfusion, treat shock if present, keep intravenous hoe open inform (I identifying the container w nded recipient matches item by item. 2. Notify Physician and Transfusion Service. The r lent is the same person ood Cornpone ion Form and 3. Follow Transfusion Reaction Procedures b)(0)-2 4. Do NOT discard unit Return Blood sag. Filter Set. and LV. solutions to he Blood Beni
. DESCRIPTION OF REACTION
URTICARIA D CHILL . FEVER L3 PAIN
n OTHER (Specify)
TH R DIFFICULT/ES (EoulL C/DIS, etc.)
.V.Ferc4111116.
)(8)-2
TEMP. C't PULS cos
DATE OF TRANSFUSION I TIME STARTED
1I O.
r
PATIENTICENTFr_ATION-LEE EMBOSSER (For typed or written entries give: Name—Last; st, re,gieue, ienn,
bx6H , hospital or medical facility)
BLOOD OR BLOOD COMPONENT TRANSFUS101
M EDCOM - 5778
Medical Record
DOD 12990
S GPO 1993-0-356 139180643
7,
ID 1 f'L
c A
71E.tac 00 •
NSN 7540-00-634-4159
VENT TRANSFUSION
"
,N)e0 taco ot4a..s"-
0 c;--akK. 0o
6nsmvoNLA-N
. Rh IMMUNEIMMUNE GLOBULIN
. OTHER (Specify) VOLUME REQUESTED (fr applicable)
\ 0,14-
REMARKS
UNIT N.0
a 014--S—
I L-N4,-Vfq 03
DONOR RECIPIENT.
Po of mptv
DATE AND HOUR REQUIRtu
KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
ML OD-ie
IF PATIENT IS FEMALE. IS THERE HISTORY CF RhIG TREATIr? IVEN: HEMOLYTIC NaSE F N WBORN7
SECTION II -PRE-TRANSFUSIONTESTING
TEST INTERPRETATION ANTIBODY SCREEN CROSSMATCH
csNP4
2CS
REQUESTING PHYSICIAN (Print)
Dv_
DIAGNOSIS CR OPERATIVE PROCEDURE
CoSu.D tieAt2a-1
I have collected a blood specimen on The below named patient verified the name and ID No of the patient and verified the specimen tube label tc be correct
SIGNATURE OF VERIFIER b3(6)-2
MOki o3
TIME VERIFIED
Co
RE IOUS RECORD CHECK:
RECORD El NO REC ORD
SIGN T IPF pFPVIki-PFRFORMI N G TEST
13)(5)-2
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUE
Eq 1,K¦104-kk
REMARKS:
ABO
Rh
SECTION III — RECORD OF TRANSFUSION
• ‘-kt-‘ Pi S-10
PRE-TRANSFUSION DATA
INSPECTPX6)-2
AT (Hour) 0 CI Cf, I ON (Date) q
IDENTIFICATION
I have examined the Blood Component container label and this form and find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and
on the patient identification tag.
1st VERIFIER (Signature)
bX6)-2
\\I At-)
(b)(8)-2
65C, (c-,J c
PRE-1RANSI-USium,
TEMP. qq• I PULSE C\
I C11-11
DATE OF TRANSFUSION TIME STARTED
—ot_rA4., e 0q05
POST-TRANSFUSION DATA
AMOUNT GIVEN TIME/DATE COMPLETED/INTERRUPTED
ML r u rs, , -
DIUONE [i] SUSPECTED TEMPERATURE PULSE(e). BLOOD PRESSURE
If reaction is suspected-IMMEDIATELY:
1. Discontinuetransfusion, treat shock if present. keep intravenous line open
2.
Notify Physician and Transfusion Service.
3.
Follow Transfusion Reaction Procedures.
4 Do NOT discard unit. Return Blood Bag_ Filter Set. and I.V. solutions to the Blood Scots..
DESCRIPTION CF REACTION URTICARIA CHILL FEVER PAN
• OTHER (Specify)
OTHER DIFFICULTIES (Equipment, clots. etc.) E NO YES (Specify)
[A, inc nroCnni
ABOVE
bfo)-2
L SI I" 1N--'
PATIENT IDENTIFICATION-USE EMBOSSER [For typed or written entries give: Name-Last, first, middle; grade; rank; WARD rate; hospital or medical facility)
alCU
t'1
b)(6)-4
M EDCOM -5779
BLOOD OR BLOOD COMPONENT TRANSFUSION
DOD 12991
NENT TRANSFUSION
i Blood REQUESTING PHYSICIAN (Print)
i
biae-2
DIAGNOSIS OR OPERATIVE PROCEDURE
ugel-a2ci t licuarie 'AU-1A-Jk
I have collected a blood specimen on the below
C)CPrv
named patient, verified the name and ID No. of DATE AND HOUR I4EQUI RED the patient and verified the specimen tube label to j v I rites (Specify) be correct.
VOLUME REQUESTED (If applicable). KNOWN ANTIBODY FORMATION/TRANSF ;x0).2 —
SION REACTIO pecify)
k LINA. ML
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY DATE VERIFIED
OF: atD RhIG ? DATE GIVEN .
TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN?
cko 0
13116)-2
SECTION II — PRE-TRANSFUSION TESTING
UNIT NO. bz3/..4...cct icinnt Nr1 REVIOUS RECORD CHECK:
TEST INTERPRETATION
torkf4NA O s ANTIBODY SCREEN CROSSMATCH RECORD n NO RECORD
At ILN I Nu. orocnN PERFORMING TEST
6)(6)-2
164D 3 CID nc
DONOR RECIPIENT
CROSSMATCH NOT REQUIRED FOR THE COMPONENT AEQUESTEDLD ATE AMN ASO ABO REMARKS:
Rh Rh
dos
Po S
SECTION til — RECORD OF TRANSFUSION
FUSION DATA POSTTRANSFUSION DATA INSPECTED AN AMOUNT GIVEN 1TIME DATE COMPLETED -INTERRUPTED
ML I g MF Q003 I 0.0
REACTION
NONE 1-1 SUSPECTED
AT (1-1tur) -5. ON (Date J —CFMATO3
(111(6) 1315
IDENTIFICATION' If reaction is suspected — IMMEDIATELY: I
1. Discontinue transfusion, treat shock if present, keep intravenous line open.
I have examined the Blood Component container label and this form and I 2. Notify Physician and Transfusion Service.
find all information identifying the container with the intended recipient 3. Follow Transfusion Reaction Procedures.
matches item by item. The recipient is the same person named on this Blood 4. Do NOT discard unit. Return Blood Bag, Filter Set. and I.V. solutions to Component Transfusion Form and on the patient identification tea.
the Blood Bank.
1st v E E Ft (Signature) DESCRIPTION
I I URTICARIA (I CHILL I 1 FEVE,, n PAIN
•
o 51c.Jilk
n OTHER
OTHER DIFFICULTIES (Equipment, riots, ele,)
PRE-TRANS ri NO . YES (Specify)
SIGNATURE OF PERSON NOTING ABOVE EP Wale
TEMP. CO PULSE ‘61)
b)(6)-2
DATE OF TRANSFUSION I TIME STARTED
PATIENT IDENTIFICATION . USE EMBOSSER (For typed or written entries e atx
NAMP, . Lost, first. middle; rash/rate; hospital number and name of facility.)
(b)(6)-4
BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. 8 -861 General Services Administration Interagency Committee on Medical Records FIRMR (41CFR) 201-45.505 518-122
MEDCOM -5780
DOD 12992