[Hospital Name]

[HospitalAddress]
 
BLOOD AND BLOOD COMPONENT TRANSFUSION MONITORING
(For Use In wards/ICU/Emergency/Dialysis/HDU)
[tableIPPatientInfo]
Pre Transfusion Blood and Blood Component Bag check(To be filled by Doctor) :

Consent For Transfusion Taken

: [ConsentForTransfusion]

Type Of Blood Component To be Transfused(please encircle)

 : [TypeOfBloodComppnent]

Blood Group

 : Patient [BloodGroup]
Bag No [bagno]
Date Of Collection [dateofcollection]
Date Of Expiry [dateofexpiry]
Blood Group [bldgrp]

Patient Vitals
Pulse [Pulse] BP [BP] Respiratory Rate [RespRate]
Temperature [Temperature] SPO2 [Spo2]

Special Instructions

In Case of reaction stop transfusion immediately and inform doctor, follow instructions given in the compatibility form.
[SpecialInstrn]
[Chkdetails]
Nurses's Sign ..................................................... Name ......................................................................................................................... Date/Time .................................................................

Transfusion Monitoring

Date Before Blood Collection

Time

Pulse/HR
(/min)

BP
(mmHG)

Temperature
(℃)

Respiratory Rate
(/min)

Sign/Name
/Clock No

Before Starting Transfusion

 [Time1] [Pulse1] [BP1] [Temperature1] [Respiration1]

15 Min After

 [Time2] [Pulse2] [BP2] [Temperature2] [Respiration2]

Hourly

 [Time3] [Pulse3] [BP3] [Temperature3] [Respiration3]

Hourly

 [Time4] [Pulse4] [BP4] [Temperature4] [Respiration4]

Hourly

 [Time5] [Pulse5] [BP5] [Temperature5] [Respiration5]

Hourly

 [Time6] [Pulse6] [BP6] [Temperature6] [Respiration6]

End

 [Time7] [Pulse7] [BP7] [Temperature7] [Respiration7]
Note
* More Frequent Vital signs should be taken if the patient has an unstable underlying condition or if the patient becomes unwell or shows signs of a Transfusion Reaction.
* If There has been a reaction do not discard the pack.inform the blood bank immediately.Fill up the blood Reaction Form. Send the blood product pack along with relevant samples and the compatibility form to the blood bank for further Evaluation keep the line IV Patent.
 
 
Printed Date : [PrintDate]     Signature & Stamp
[DSALU]. [DoctorName]
 [DocQualification] , [Speciality]