Therapeutic Phlebotomy Procedure Note

Date/Time of Procedure: Start: [Procedure start date/time]; Stop: [Procedure end date/time]

Location: [Infusion center / Clinic / Bedside / Other: specify]

Performer: [Name], [Credential]

Supervising/Ordering Clinician: [Name], [Credential] (if different from performer)

Procedure Status: [Completed / Partially completed / Aborted / Deferred]

Indication and Targets

Indication: [Hereditary hemochromatosis / Secondary iron overload / Polycythemia vera / Porphyria cutanea tarda / Other: rationale]

Treatment Phase: [Induction/Depletion / Maintenance]

• Protocol: [Per protocol name / Individualized plan]
• Therapeutic Targets: [Target ferritin (ng/mL) and/or transferrin saturation (%) for iron overload; Target hematocrit (%) for PV; Other targets as ordered]
• Proceed/Hold Criteria: [Minimum hemoglobin (g/dL) to proceed; Hematocrit threshold; Other explicit proceed/hold parameters as ordered]

Pre-Procedure Assessment

• Pre-procedure Vitals: BP [value] HR [value], [Patient position], [Date/time measured]
• Recent Labs Reviewed:
  • Hemoglobin: [value g/dL]; Collection: [date/time]
  • Hematocrit: [value %]; Collection: [date/time]
  • Ferritin: [value ng/mL]; Collection: [date/time] (iron overload only)
  • Transferrin saturation: [value %]; Collection: [date/time] (iron overload only)
  • [Other relevant labs if reviewed: test, value, units; collection date/time]
  (Document actual values with units and exact collection date/time; do not infer from prior values.)
• Risk Screen: Prior vasovagal reaction: [Yes/No]; Anticoagulation/bleeding risk: [Yes/No; details if Yes]; Cardiac/pulmonary conditions affecting volume tolerance: [Yes/No; details if Yes]; Other: [specify or None]

Proceed Decision: [Proceed / Hold] — [Brief rationale tying decision to order parameters and today's data, e.g., "Hgb meets minimum; ferritin remains above target" or "Hold—required labs unavailable"]

(If required labs unavailable, document explicitly whether procedure was held or performed under exception with rationale.)

Consent and Safety Verification

Consent: [Written / Verbal / Standing consent on file] obtained from [Patient / Legal representative]. Risks (syncope, hematoma, nerve injury, hypovolemia) and alternatives discussed; patient verbalized understanding and agreed to proceed.

Time-out: [Completed—correct patient, procedure, and site confirmed / Not required per facility policy]

Procedure

[One-sentence summary: indication, total volume removed in mL, venipuncture site, and overall tolerance]

• Patient Position: [Supine / Semi-recumbent / Seated / Other]
• Venipuncture Site: [Left / Right] [antecubital / forearm / hand / Other: specify]
• Skin Antisepsis: [Chlorhexidine / Alcohol / Povidone-iodine]; aseptic technique maintained
• Access and Collection: [Gauge] needle via [Vacuum collection bag / Gravity collection / Syringe]
• Volume: Planned [mL]; Actual [mL] (If stopped early or aborted, document reason; use "0 mL" if no blood removed)
• Venipuncture Attempts: [Number]
• Fluids Administered: [None / Oral: type and volume / IV: type, rate, and total volume]
• Blood Disposition: [Discarded per policy / Sent to blood bank]
• Hemostasis: Pressure applied [duration]; [Adhesive bandage / Gauze / Pressure dressing] applied
• Post-site Assessment: [No bleeding, hematoma, or paresthesia / Findings: describe]

Monitoring and Adverse Events

Post-procedure Vitals: BP [value] HR [value] at [time]; observed for [duration]

Symptoms During/After: [None / Dizziness / Lightheadedness / Nausea / Paresthesia / Other: specify]

Adverse Events: No adverse events; tolerated well.

(If adverse event occurred, replace above with structured documentation:)

• Event Type: [Vasovagal / Hypotension / Hematoma / Nerve irritation / Failed access / Other]
• Severity and Findings: [Mild / Moderate / Severe]; [Objective findings including vital sign changes, LOC if applicable]
• Interventions: [Trendelenburg / Fluids / Cold compress / Pressure / Observation / Other]
• Outcome: [Resolved / Improved / Ongoing]; [Patient status at discharge]
• Notifications: Ordering clinician notified: [Yes / No]; Incident report filed: [Yes / No / N/A]

Discharge and Instructions

Condition at Discharge: [Alert, ambulatory, no symptoms, tolerating oral intake / Other: describe]

Instructions Provided: Standard post-procedure guidance including hydration, activity restrictions, site care, and return precautions (bleeding, swelling, severe dizziness, syncope, numbness, signs of infection).

Plan

Interpretation vs Targets: [Assessment of today's session relative to therapeutic targets, e.g., "Ferritin remains above induction target; continue phlebotomy" or "Hct above goal; phlebotomy indicated per protocol" or "Hold criteria met; session deferred"]

• Monitoring Plan: [Next labs and timing, e.g., Hgb/Hct in 1 week, ferritin in 4 weeks]
• Next Session: [Specific date or interval; include prerequisite labs if applicable]
• Clinician Reassessment: [Timing or visit type for review of response/tolerance]

(If procedure was deferred or aborted, ensure documentation includes intended indication, data reviewed, specific reason for deferral/early termination, patient counseling, and revised plan.)