Blood Transfusion Administration & Reaction Monitoring Note

Date/Time: [Date and time of transfusion start]    Location: [Unit/bed/clinic and service]    Ordering Clinician: [Name and role]    Administering Clinician: [Name and role]    Second Verifier: [Name and role, or automated verification method used]

Transfusion Episode Overview

[Indication for transfusion]

• Component(s) Ordered: [Component type and dose/units]
• Urgency: [scheduled / urgent / emergent / massive transfusion protocol]
• Special Product Requirements: [leukocyte-reduced / irradiated / CMV-negative / HLA-matched / antigen-negative / washed / pathogen-reduced / volume-reduced / sickle-negative / none]
• Transfusion History: [Prior transfusions, prior reactions with type/severity, special precautions from transfusion service, or "Transfusion history unknown/unavailable"]

Consent

Consent Status: [obtained / previously obtained per policy / emergent exception / patient refused]    Date/Time Obtained: [Date and time]    Obtained By: [Name and role]    Mode: [written / verbal]    Interpreter Used: [yes / no / N/A]

(If emergent exception: document emergency rationale and authorizing clinician. If patient refused: document component(s) refused, patient-stated rationale, alternatives discussed, and that treating clinician was notified.)

Pre-Transfusion Safety Verification

Order Verification: [Active order confirmed including component, dose/units, rate constraints, special requirements, and premedication/diuretic orders if applicable]

Patient Identification: [Two identifiers used]    Verification Method: [two-person check / one-person with barcode/RFID]    Verifiers: [Names and roles]    Time: [Timestamp]

Blood Component Verification: (Repeat for each unit)

• Unit Number: [Donation/unit number]
• Component: [RBCs / platelets / plasma / cryoprecipitate / whole blood]
• ABO/Rh: Unit [ABO/Rh]   Recipient [ABO/Rh]
• Compatibility: [crossmatch compatible / electronic crossmatch / emergency release uncrossmatched / group-specific uncrossmatched]
• Expiration: [Date and time]
• Special Processing Confirmed: [Processing type(s) or none]
• Visual Inspection: [Bag integrity intact / no discoloration / no clots or particulate / no leakage]

Patient Readiness: [Vascular access type and patency confirmed] [Baseline condition: fever, respiratory status, volume overload risk, unstable vitals, sedation] [Equipment: administration set/filter, pump vs gravity, warmer if used]

(If any verification step deviated from policy, document the deviation and corrective action taken.)

Baseline Assessment

Temp: [Value]   BP: [Value]   HR: [Value]   RR: [Value]   SpO2: [Value]

(If any vital not obtained, document "Not obtained" with reason and first available value/time.)

Baseline Status: [Respiratory status/lung exam findings, presence/absence of rash, presence/absence of chills/dyspnea/chest or back pain]

Patient Education: [Patient instructed to report symptoms immediately: confirmed / unable to educate due to sedation or altered status]

Administration Details

(Document separately for each unit transfused)

• Unit Number: [Unit number]    Component: [Component type]
• Start Time: [Time]    Stop/Completion Time: [Time]
• Initial Rate: [mL/hr]    Rate Changes: [Times and rationale, or none]
• Total Volume Infused: [mL] [entire unit / partial - specify reason]
• Premeds/Diuretics: [Medication, dose, route, time, or none given]
• Pauses: [Pause time, reason, restart authorization, or none] (Only include if transfusion was paused)

Monitoring During Transfusion

Time	Temp	BP	HR	RR	SpO2	Symptoms/Observations	Actions
Baseline	[Value]	[Value]	[Value]	[Value]	[Value]	[Baseline observations]	[Education provided]
~15 min	[Value]	[Value]	[Value]	[Value]	[Value]	[Symptoms or "Denies symptoms, vitals stable, no skin changes"]	[Actions or none]
[Periodic check]	[Value]	[Value]	[Value]	[Value]	[Value]	[Symptoms/observations]	[Actions]
Completion	[Value]	[Value]	[Value]	[Value]	[Value]	[Patient condition]	[Actions]
Post-transfusion	[Value]	[Value]	[Value]	[Value]	[Value]	[Symptoms/observations]	[Actions]

Completion and Post-Transfusion Care

• Completion Time: [Time]    Total Volume Infused: [mL]
• Line Disposition: [flushed / maintained / removed per policy]
• Patient Condition at Completion: [Brief status]
• Follow-up Labs: [Ordered and collected / ordered, pending collection / not ordered]
• Delayed Reaction Education: [Provided with contact instructions / N/A for inpatient] (Include for outpatient or short-stay settings)

Tolerance Statement

[Patient tolerated transfusion without signs or symptoms of reaction during the monitored period / Patient developed signs or symptoms concerning for transfusion reaction—see Reaction Documentation below]

Reaction Documentation

(Include this section only if new or worsening symptoms or significant vital sign changes occurred during transfusion or within the post-transfusion monitoring window.)

Reaction Onset

Time Symptoms Noted: [Date and time]    Time from Transfusion Start: [Duration]    Volume Infused at Onset: [mL]    Unit at Onset: [Unit number and component]

Signs and Symptoms

Present: [fever / chills or rigors / urticaria or pruritus / flushing / dyspnea or bronchospasm / hypoxia / hypotension / hypertension / chest, back, or flank pain / nausea or vomiting / infusion site pain / dark urine or hemoglobinuria / bleeding or DIC signs]

[Narrative description of symptom sequence and severity in time order, including patient-reported symptoms]

Immediate Actions

Transfusion Stopped: [Time]    IV Access: [Maintained with method]    Assessment: [Airway/breathing/circulation and repeat vitals]    Clerical Re-check: [Correct unit confirmed to correct patient]    Unit/Tubing: [Retained and sent per policy]

Notifications

Treating Provider: [Name, role, time notified]    Blood Bank: [Time notified]    Rapid Response/Code: [Time activated, or not required]    Additional Consults: [Services consulted, or none]

Treatment Administered

[Medications with drug, dose, route, time, and response] [Oxygen or ventilation changes] [Fluids, pressors, or diuretics if used]

Reaction Workup

Investigation Initiated: [yes / no]    Specimens Collected: [Post-transfusion blood sample, urine - times sent]    Blood Bag/Tubing Sent: [yes / no, time]    Additional Testing: [Cultures, imaging ordered, or none]

Outcome

Symptom Status: [resolved / persisted / progressed]    Patient Disposition: [continued monitoring / transfer to higher level of care / discharged with precautions]

(If transfusion restarted: document time, authorizing clinician, evaluation performed, and criteria met.)

Documentation Updated: [Chart flags, problem list, and transfusion reaction history updated: yes / no]

Signatures

Administering Clinician: [Signature and timestamp]    Second Verifier: [Signature]

(If reaction occurred, include signature of clinician who evaluated the patient and authorized restart or cessation.)