Health Adms Solutions

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.:

Labels