Patient Unit #:

Patient Name:
Date of Birth :
Patient Phys :
Hosp, Location:
Lab Specimen#:

012221
Account #: IN000000/04
John Smith
06/29/1951
DOOLITTLE, DR
4B
426-1
ADM IN
0808:BB00001U

Patient Blood Type:

[B NEG]

[B NEG]

Wristband #:

BLOOD COMPONENT
ISSUE/ADMINISTRATION
RECORD
R1234

RED CELLS LEUCOREDUCED

Lot#: 567392
Received: 4/30/13 1700
Compatible: Y 05/08/13

Received from: Canadian Blood Services

Expires: 05/28/13 2230
Volume: 300ml.
Status: Issued

ISSUED TO MESSENGER ON DATE: ___________ TIME: ____________

VITAL SIGNS
Pre Administration:
Time: _________________________
BP:_____ T:_____ P:_____ R:_____

During Administration:
Time

TECH: _________ INSPECTED BY: _________ MESSENGER: _________

BP

Init

Comments: After transfusion is finished, return the yellow copy of this form
together with segments and yellow tags (if red cell product), to the
Blood Bank. Return product within 20 min. if Transfusion cannot be
started. If a reaction occurs, return all units to Blood Bank.
*COMPLETE THE FOLLOWING WHEN PRODUCT TRANSFUSED*
Product arrived at Nursing Unit on Date: _________ Time: ________
Time Transfusion Started: __________ Ended: __________
Volume Transfused: ____________
Administered by: __________

Reaction (Y/N): _______ (see below)

ID Checked by: __________

Transfusion Related Comments:

Comments: _____________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________

____________________________

BLOOD COMPONENT REACTION REPORT

Clinical Signs and Symptoms of Reaction: _________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Physician notified at: ___________ by: _____________________
Blood Bank notified at: _________ by: _____________________
Patient ID, witness sheet, blood unit number rechecked at: ____________ by: ______________
Transfusion Reaction Investigation blood samples drawn at: ___________ by: ______________
PERMANENT CHART COPY

Patient Unit #:
Patient Name:
Date of Birth :
Patient Phys :
Hosp, Location:
Lab Specimen#:

012221
Account #: IN000000/04
John Smith
06/29/1951
DOOLITTLE, DR
4B
426-1
ADM IN
0808:BB00001U

Patient Blood Type:

[B POS]

[B POS]

Wristband #:

R1234

RED CELLS LEUCOREDUCED

Lot#: 567392
Received: 4/30/13 1700
Compatible: Y 05/08/13

BLOOD COMPONENT
ISSUE/ADMINISTRATION
RECORD

Received from: Canadian Blood Services

Expires: 05/28/13 2230
Volume: 300ml.
Status: Issued

ISSUED TO MESSENGER ON DATE: ___________ TIME: ____________

VITAL SIGNS
Pre Administration:
Time: _________________________
BP:_____ T:_____ P:_____ R:_____

During Administration:
Time

TECH: _________ INSPECTED BY: _________ MESSENGER: _________

BP

Init

Comments: After transfusion is finished, return the yellow copy of this form
together with segments and yellow tags (if red cell product), to the
Blood Bank. Return product within 20 min. if Transfusion cannot be
started. If a reaction occurs, return all units to Blood Bank.
*COMPLETE THE FOLLOWING WHEN PRODUCT TRANSFUSED*
Product arrived at Nursing Unit on Date: _________ Time: ________
Time Transfusion Started: __________ Ended: __________
Volume Transfused: ____________
Administered by: __________

Reaction (Y/N): _______ (see below)

ID Checked by: __________

Transfusion Related Comments:

Comments: _____________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________

____________________________

BLOOD COMPONENT REACTION REPORT

Clinical Signs and Symptoms of Reaction: _________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Physician notified at: ___________ by: _____________________
Blood Bank notified at: _________ by: _____________________
Patient ID, witness sheet, blood unit number rechecked at: ____________ by: ______________
Transfusion Reaction Investigation blood samples drawn at: ___________ by: ______________
PERMANENT CHART COPY

Patient Unit #:
Patient Name:
Date of Birth :
Patient Phys :
Hosp, Location:
Lab Specimen#:

012221
Account #: IN000000/04
John Smith
06/29/1951
DOOLITTLE, DR
4B
426-1
ADM IN
0808:BB00001U

Patient Blood Type:

[A NEG]

[A NEG]

Wristband #:

BLOOD COMPONENT
ISSUE/ADMINISTRATION
RECORD
R1234

RED CELLS LEUCOREDUCED

Lot#: 567392
Received: 4/30/13 1700
Compatible: Y 05/08/13

Received from: Canadian Blood Services

Expires: 05/28/13 2230
Volume: 300ml.
Status: Issued

ISSUED TO MESSENGER ON DATE: ___________ TIME: ____________

VITAL SIGNS
Pre Administration:
Time: _________________________
BP:_____ T:_____ P:_____ R:_____

During Administration:
Time

TECH: _________ INSPECTED BY: _________ MESSENGER: _________

BP

Init

Comments: After transfusion is finished, return the yellow copy of this form
together with segments and yellow tags (if red cell product), to the
Blood Bank. Return product within 20 min. if Transfusion cannot be
started. If a reaction occurs, return all units to Blood Bank.
*COMPLETE THE FOLLOWING WHEN PRODUCT TRANSFUSED*
Product arrived at Nursing Unit on Date: _________ Time: ________
Time Transfusion Started: __________ Ended: __________
Volume Transfused: ____________
Administered by: __________

Reaction (Y/N): _______ (see below)

ID Checked by: __________

Transfusion Related Comments:

Comments: _____________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________

____________________________

BLOOD COMPONENT REACTION REPORT

Clinical Signs and Symptoms of Reaction: _________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Physician notified at: ___________ by: _____________________
Blood Bank notified at: _________ by: _____________________
Patient ID, witness sheet, blood unit number rechecked at: ____________ by: ______________
Transfusion Reaction Investigation blood samples drawn at: ___________ by: ______________
PERMANENT CHART COPY

Patient Unit #:
Patient Name:
Date of Birth :
Patient Phys :
Hosp, Location:
Lab Specimen#:

012221
Account #: IN000000/04
John Smith
06/29/1951
DOOLITTLE, DR
4B
426-1
ADM IN
0808:BB00001U

Patient Blood Type:

[A POS]

[A POS]

Wristband #:

R1234

RED CELLS LEUCOREDUCED

Lot#: 567392
Received: 4/30/13 1700
Compatible: Y 05/08/13

BLOOD COMPONENT
ISSUE/ADMINISTRATION
RECORD

Received from: Canadian Blood Services

Expires: 05/28/13 2230
Volume: 300ml.
Status: Issued

ISSUED TO MESSENGER ON DATE: ___________ TIME: ____________

VITAL SIGNS
Pre Administration:
Time: _________________________
BP:_____ T:_____ P:_____ R:_____

During Administration:
Time

TECH: _________ INSPECTED BY: _________ MESSENGER: _________

BP

Init

Comments: After transfusion is finished, return the yellow copy of this form
together with segments and yellow tags (if red cell product), to the
Blood Bank. Return product within 20 min. if Transfusion cannot be
started. If a reaction occurs, return all units to Blood Bank.
*COMPLETE THE FOLLOWING WHEN PRODUCT TRANSFUSED*
Product arrived at Nursing Unit on Date: _________ Time: ________
Time Transfusion Started: __________ Ended: __________
Volume Transfused: ____________
Administered by: __________

Reaction (Y/N): _______ (see below)

ID Checked by: __________

Transfusion Related Comments:

Comments: _____________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________

____________________________

BLOOD COMPONENT REACTION REPORT

Clinical Signs and Symptoms of Reaction: _________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Physician notified at: ___________ by: _____________________
Blood Bank notified at: _________ by: _____________________
Patient ID, witness sheet, blood unit number rechecked at: ____________ by: ______________
Transfusion Reaction Investigation blood samples drawn at: ___________ by: ______________
PERMANENT CHART COPY

Patient Unit #:
Patient Name:
Date of Birth :
Patient Phys :
Hosp, Location:
Lab Specimen#:

012221
Account #: IN000000/04
John Smith
06/29/1951
DOOLITTLE, DR
4B
426-1
ADM IN
0808:BB00001U

Patient Blood Type:

[AB NEG]

[AB NEG]

Wristband #:

BLOOD COMPONENT
ISSUE/ADMINISTRATION
RECORD
R1234

RED CELLS LEUCOREDUCED

Lot#: 567392
Received: 4/30/13 1700
Compatible: Y 05/08/13

Received from: Canadian Blood Services

Expires: 05/28/13 2230
Volume: 300ml.
Status: Issued

ISSUED TO MESSENGER ON DATE: ___________ TIME: ____________

VITAL SIGNS
Pre Administration:
Time: _________________________
BP:_____ T:_____ P:_____ R:_____

During Administration:
Time

TECH: _________ INSPECTED BY: _________ MESSENGER: _________

BP

Init

Comments: After transfusion is finished, return the yellow copy of this form
together with segments and yellow tags (if red cell product), to the
Blood Bank. Return product within 20 min. if Transfusion cannot be
started. If a reaction occurs, return all units to Blood Bank.
*COMPLETE THE FOLLOWING WHEN PRODUCT TRANSFUSED*
Product arrived at Nursing Unit on Date: _________ Time: ________
Time Transfusion Started: __________ Ended: __________
Volume Transfused: ____________
Administered by: __________

Reaction (Y/N): _______ (see below)

ID Checked by: __________

Transfusion Related Comments:

Comments: _____________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________

____________________________

BLOOD COMPONENT REACTION REPORT

Clinical Signs and Symptoms of Reaction: _________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Physician notified at: ___________ by: _____________________
Blood Bank notified at: _________ by: _____________________
Patient ID, witness sheet, blood unit number rechecked at: ____________ by: ______________
Transfusion Reaction Investigation blood samples drawn at: ___________ by: ______________
PERMANENT CHART COPY

Patient Unit #:
Patient Name:
Date of Birth :
Patient Phys :
Hosp, Location:
Lab Specimen#:

012221
Account #: IN000000/04
John Smith
06/29/1951
DOOLITTLE, DR
4B
426-1
ADM IN
0808:BB00001U

Patient Blood Type:

[AB POS]

[AB POS]

Wristband #:

BLOOD COMPONENT
ISSUE/ADMINISTRATION
RECORD
R1234

RED CELLS LEUCOREDUCED

Lot#: 567392
Received: 4/30/13 1700
Compatible: Y 05/08/13

Received from: Canadian Blood Services

Expires: 05/28/13 2230
Volume: 300ml.
Status: Issued

ISSUED TO MESSENGER ON DATE: ___________ TIME: ____________

VITAL SIGNS
Pre Administration:
Time: _________________________
BP:_____ T:_____ P:_____ R:_____

During Administration:
Time

TECH: _________ INSPECTED BY: _________ MESSENGER: _________

BP

Init

Comments: After transfusion is finished, return the yellow copy of this form
together with segments and yellow tags (if red cell product), to the
Blood Bank. Return product within 20 min. if Transfusion cannot be
started. If a reaction occurs, return all units to Blood Bank.
*COMPLETE THE FOLLOWING WHEN PRODUCT TRANSFUSED*
Product arrived at Nursing Unit on Date: _________ Time: ________
Time Transfusion Started: __________ Ended: __________
Volume Transfused: ____________
Administered by: __________

Reaction (Y/N): _______ (see below)

ID Checked by: __________

Transfusion Related Comments:

Comments: _____________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________

____________________________

BLOOD COMPONENT REACTION REPORT

Clinical Signs and Symptoms of Reaction: _________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Physician notified at: ___________ by: _____________________
Blood Bank notified at: _________ by: _____________________
Patient ID, witness sheet, blood unit number rechecked at: ____________ by: ______________
Transfusion Reaction Investigation blood samples drawn at: ___________ by: ______________
PERMANENT CHART COPY

Patient Unit #:
Patient Name:
Date of Birth :
Patient Phys :
Hosp, Location:
Lab Specimen#:

012221
Account #: IN000000/04
John Smith
06/29/1951
DOOLITTLE, DR
4B
426-1
ADM IN
0808:BB00001U

Patient Blood Type:

[O NEG]

[O NEG]

Wristband #:

BLOOD COMPONENT
ISSUE/ADMINISTRATION
RECORD
R1234

RED CELLS LEUCOREDUCED

Lot#: 567392
Received: 4/30/13 1700
Compatible: Y 05/08/13

Received from: Canadian Blood Services

Expires: 05/28/13 2230
Volume: 300ml.
Status: Issued

ISSUED TO MESSENGER ON DATE: ___________ TIME: ____________

VITAL SIGNS
Pre Administration:
Time: _________________________
BP:_____ T:_____ P:_____ R:_____

During Administration:
Time

TECH: _________ INSPECTED BY: _________ MESSENGER: _________

BP

Init

Comments: After transfusion is finished, return the yellow copy of this form
together with segments and yellow tags (if red cell product), to the
Blood Bank. Return product within 20 min. if Transfusion cannot be
started. If a reaction occurs, return all units to Blood Bank.
*COMPLETE THE FOLLOWING WHEN PRODUCT TRANSFUSED*
Product arrived at Nursing Unit on Date: _________ Time: ________
Time Transfusion Started: __________ Ended: __________
Volume Transfused: ____________
Administered by: __________

Reaction (Y/N): _______ (see below)

ID Checked by: __________

Transfusion Related Comments:

Comments: _____________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________

____________________________

BLOOD COMPONENT REACTION REPORT

Clinical Signs and Symptoms of Reaction: _________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Physician notified at: ___________ by: _____________________
Blood Bank notified at: _________ by: _____________________
Patient ID, witness sheet, blood unit number rechecked at: ____________ by: ______________
Transfusion Reaction Investigation blood samples drawn at: ___________ by: ______________
PERMANENT CHART COPY

Patient Unit #:
Patient Name:
Date of Birth :
Patient Phys :
Hosp, Location:
Lab Specimen#:

012221
Account #: IN000000/04
John Smith
06/29/1951
DOOLITTLE, DR
4B
426-1
ADM IN
0808:BB00001U

Patient Blood Type:

[O POS]

[O POS]

Wristband #:

BLOOD COMPONENT
ISSUE/ADMINISTRATION
RECORD
R1234

RED CELLS LEUCOREDUCED

Lot#: 567392
Received: 4/30/13 1700
Compatible: Y 05/08/13

Received from: Canadian Blood Services

Expires: 05/28/13 2230
Volume: 300ml.
Status: Issued

ISSUED TO MESSENGER ON DATE: ___________ TIME: ____________

VITAL SIGNS
Pre Administration:
Time: _________________________
BP:_____ T:_____ P:_____ R:_____

During Administration:
Time

TECH: _________ INSPECTED BY: _________ MESSENGER: _________

BP

Init

Comments: After transfusion is finished, return the yellow copy of this form
together with segments and yellow tags (if red cell product), to the
Blood Bank. Return product within 20 min. if Transfusion cannot be
started. If a reaction occurs, return all units to Blood Bank.
*COMPLETE THE FOLLOWING WHEN PRODUCT TRANSFUSED*
Product arrived at Nursing Unit on Date: _________ Time: ________
Time Transfusion Started: __________ Ended: __________
Volume Transfused: ____________
Administered by: __________

Reaction (Y/N): _______ (see below)

ID Checked by: __________

Transfusion Related Comments:

Comments: _____________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________

____________________________

BLOOD COMPONENT REACTION REPORT

Clinical Signs and Symptoms of Reaction: _________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Physician notified at: ___________ by: _____________________
Blood Bank notified at: _________ by: _____________________
Patient ID, witness sheet, blood unit number rechecked at: ____________ by: ______________
Transfusion Reaction Investigation blood samples drawn at: ___________ by: ______________
PERMANENT CHART COPY