BLOOD TRANSFUSION ADVERSE REACTION FORM

                           BLOOD TRANSFUSION ADVERSE REACTION FORM 

TO BE FILLED IN BY BLOOD BANK STAFF:

Bag No. :                                                                            Date & Time of Issue:

Patient’s Name:                                                                 Ward:

Patient’s Blood Group:                                                     UHID No.:

Blood Bank Name:                                                            Blood Serial No.:

Cross Matched By:                                                            Issued By:

TO BE COMPLETED BY THE DOCTOR INCHARGE OF TRANSFUSION TO THE PATIENT

1. Patient Name:                                                                                 UHID No.:

2. Temperature of Patient before Transfusion:

3. Date of Transfusion:

4. Time Started:

5. Time Completed:

6. Reaction Noticed:

   (a) Pyrexia - Rise in temperature to 100⁰F but no subjective symptoms                         YES / NO

                       - Rise in temperature to 100⁰F or above feeling of cold but no rigor           YES / NO

                       - Rigor                                                                                                                 YES / NO

    (b) PAIN

          Loin                                                                                                                                  YES / NO

          Site of transfusion                                                                                                          YES / NO

          Chest                                                                                                                                YES / NO

          Elsewhere (Specify)

    (c) JAUNDICE                                                                                                                        YES / NO

    (d) HAEMOGLOBINUREA                                                                                                     YES / NO

    (e) ANURIA                                                                                                                             YES / NO

    (f)  ANY OTHER UNTOWARD REACTIONS                                                                         YES / NO

          IF YES SPECIFY:

Dated:

                                                                                                                                               

                                                                                                                          Signature of the

                                                                                                                    Doctor responsible for

                                                                                                                             Transfusion

Name in Block Letters:

Registration No.: