Scribd
Upload
60 views2 pages

BTR Form 2025

The document is a Blood Transfusion Reaction Investigation Form for a patient named Juan Anon Dela Cruz, detailing the transfusion process and any observed reactions. It includes sections for clerical verification, vital signs, types of reactions, and tests to be performed by medical staff. The form is to be filled out by both the nurse or physician in charge and the medical technologist on duty to ensure proper investigation of any transfusion reactions.

Uploaded by

Ernesto Sumaoang
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
60 views2 pages

BTR Form 2025

The document is a Blood Transfusion Reaction Investigation Form for a patient named Juan Anon Dela Cruz, detailing the transfusion process and any observed reactions. It includes sections for clerical verification, vital signs, types of reactions, and tests to be performed by medical staff. The form is to be filled out by both the nurse or physician in charge and the medical technologist on duty to ensure proper investigation of any transfusion reactions.

Uploaded by

Ernesto Sumaoang
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 2

BLOOD TRANSFUSION REACTION

INVESTIGATION FORM

PATIENT’S NAME ORDER DATE & TIME


DELA CRUZ, Juan Anon 12/07/2024 09:30 PM
AGE SEX DATE OF BIRTH WARD CASE NO. ACCESSION NO. REQUESTING PHYSICIAN
68 M 02/22/1956 Medical 27485 Dr. Juan A. dela Cruz

I. To be filled-out by the Nurse or Physician in-Charge:


NAME:

Blood Product: PRBC Time Started: 09:55 PM Blood Unit Serial No.:
Volume Transfused: 200 mL Time Stopped: 10:20 PM Unit Segment No.:

A. CLERICAL VERIFICATION
Patient ID Correct:  YES  NO Blood Unit Serial No. Correct:  YES  NO

B. VITAL SIGNS RECORD


Temperature in the 24-Hours prior to Transfusion
 Febrile:  Afebrile:
Body Temperature C Body Temperature C

Time Body Temp Respiratory Rate Blood Pressure Pulse rate


Pre-Reaction
At Time of Reaction

C. TYPE OF REACTION OBSERVED


 Minor Reaction
 Fever Only Action Taken:
 Rash/Urticaria Action Taken:

 Other Reactions: Signs and Symptoms: (Please Tick)


 Fever  Anxiety
 Chills  Headache
 Nausea/Vomiting  Skin Pallor
 Hives/Itching  Dark Urine
 Lower Back Pain  Dyspnea
 Chest Pain  Bleeding from Wound or IV Site
 Others (Please Specify):

D. PROCEED TO BLOOD TRANSFUSION REACTION INVESTIGATION:  YES  NO

II. To be filled-out by the Medical Technologist on Duty


Date & Time Notified Blood Unit Serial No.:
Blood Product Released Unit Segment No.:

A. Repeat ABO & Rh Typing of Blood Unit and Patient


Pre-Transfusion Blood Typing Post-Transfusion Blood Typing
Blood Unit
Patient
Page |1

B. Hemolysis Testing (Patient):


1. Plasma:  YES  NO
2. Urine:  YES  NO
BLOOD TRANSFUSION REACTION
INVESTIGATION FORM

Hemolyzed Not Hemolyzed


Post Transfusion Plasma  
1st Hour Urine  
2nd Hour Urine  

C. Direct Antiglobulin Test (Patient)

NEGATIVE POSITIVE (Indicate Grading)


Pre-Transfusion   Grading:
Post-Transfusion   Grading:

D. Repeat Crossmatching

NEGATIVE INCOMPATIBLE (Indicate Grading)


Pre-Transfusion   Grading:
Post-Transfusion   Grading:

E. Perform Antibody Screen (Patient):  YES  NO

POSITIVE* (Indicate Grading)


NEGATIVE
I II III
RESULT    
GRADING
*In Case of Antibody Screen is Positive, proceed to Antibody Identification

F. Perform Blood Culture:  YES  NO

RESULT  NO GROWTH  POSITIVE

G. IMPRESSION

Performed by: Validated By: Noted by:

GIAN MARIE O. LIQUIGAN, RMT JANE G. PAGADDU, MD, FPSP, MBA-H


Medical Technologist / License: 0100868 Pathologist / License: 0092657

Document No.: DMWMC-ANS-DPLM-REC-001 Printed By: ROZEL


Page |2

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy