Transfusion Order & Consent Note

Patient: [name, MRN, DOB]

Location: [unit/bed or infusion chair]

Date/Time: [note date/time]

Consent Date/Time: [consent date/time] (Only include if different from note.)

Provider: [author name, credentials, role]

Attending: [supervising clinician] (Omit if not applicable.)

Encounter Type: [inpatient / ED / peri-procedural / infusion center]; [emergent / urgent / non-emergent]

(This documentation complements but does not replace CPOE transfusion orders.)

Clinical Indication

[Primary indication and clinical rationale] (State indication such as symptomatic anemia, thrombocytopenia with bleeding, coagulopathy, or massive hemorrhage. Include current clinical status and urgency. If indication is not yet determined, state explicitly with pending data.)

• [Pertinent clinical status including bleeding, hemodynamics, symptoms]
• [Relevant laboratory values with timestamps]
• [Alternatives considered and why inadequate]
• [Urgency/timing and relation to planned procedures]

Transfusion Plan

[Summary of components ordered and overall goals]

Component	Dose/Quantity	Timing/Rate	Target Endpoint & Reassessment	Stop/Hold Criteria
[component type]	[units or weight-based volume]	[start time; rate constraints]	[target parameter(s); reassessment plan]	[criteria to pause/stop]

(Add rows as needed. For single-component orders, a simple list format may be used instead of table.)

Patient-Specific Precautions: [volume overload precautions, rate modifications, diuretic timing, split units, access considerations, premedication] (Omit if no special precautions apply.)

Special Product Requirements: [explicit requirements or "No special requirements beyond standard blood bank policy."] (Always include an explicit statement.)

• ABO/Rh: [status if known]
• Compatibility: [antibody screen/crossmatch status: compatible / incompatible / pending]
• Modifications: [irradiated / CMV-safe / washed / volume-reduced / antigen-negative / phenotype-matched / HLA-matched / other with clinical rationale] (Omit if none required.)

Consent Documentation

Capacity & Participants

[Who provided consent: patient or surrogate with relationship; capacity assessment; interpreter use if applicable; timing of discussion]

Discussion

[Narrative attestation documenting discussion of: reason for transfusion; expected benefits; material risks including common and rare-but-serious risks personalized to patient; alternatives including no transfusion; consequences of refusal; transfusion process and monitoring; opportunity for questions; right to refuse or withdraw consent]

Decision

• Consent outcome: [consented / refused / partial consent]
• Component-level permissions: [accepted and declined components] (Only include if partial consent.)
• Consent duration: [single episode / this admission / defined time period per policy]
• Documentation: [location of signed consent form or electronic attestation]

If Consent Not Obtained

[Reason: incapacity / emergent / surrogate unavailable; attempts made; clinical necessity justifying proceeding; plan for retrospective disclosure] (Only include if consent was not obtained.)

Monitoring Instructions

Follow institutional transfusion policy for identity checks, safety checks, and vital sign monitoring.

• Patient-specific modifications: [rate constraints, TACO precautions, diuretic timing, access considerations, additional monitoring] (Omit if none.)
• Escalation: Stop transfusion if reaction suspected; maintain IV access with normal saline; assess vitals; notify provider and blood bank; initiate transfusion reaction workup per protocol.