Transfusion Reaction Workup Report

Report Date/Time: [Report date and time]

Report Status: [Preliminary / Final]

Reaction Case #: [Case number]

Authoring Service: Transfusion Medicine / Blood Bank

Author: [Name, credentials]

Reviewing Physician: [Name, credentials]

Patient: [Name, MRN, DOB, sex]

Location at Reaction Onset: [Patient location]

Patient ABO/Rh: [ABO/Rh]

Transfusion and Reaction Summary

• Implicated Component(s):
  • [Component type] — [Unit identifier] — [Unit ABO/Rh]
  • Transfusion start/stop: [Start date/time] to [Stop date/time]
  • Volume infused at symptom onset: [Volume]
  (Repeat for each implicated component if multiple units.)
• Reaction onset: [Date/time]; Timing: [during transfusion / within X hours after / delayed >24 hours]
• Clinical presentation: [Predominant signs/symptoms and vital sign changes from baseline] (If clinical details were not provided on the reaction form, explicitly state this.)
• Immediate bedside actions: [Transfusion stopped yes/no; medications administered; escalation of care; other interventions]
• Indication for transfusion: [Brief clinical indication]
• Relevant history: [Prior reactions, known alloantibodies, conditions that may mimic reactions] (Only include if documented.)

Specimens and Materials Received

• Implicated unit/bag returned: [yes / no]; Condition: [intact / leaking / temperature concern / other]
• Tubing/administration set returned: [yes / no]
• Patient specimens received: [Specimen type, collection date/time, pre- or post-reaction] (List each specimen. If none received, document reason.)

Investigation Results

(For any clinically indicated test not available to the Transfusion Service, state "not assessed" rather than omitting.)

Clerical Check: [No discrepancies identified / Discrepancy identified: describe mismatch]

Visual Hemolysis Check:

• Pre-transfusion plasma/serum: [clear / icteric / lipemic / hemolyzed / not available]
• Post-transfusion plasma/serum: [clear / icteric / lipemic / hemolyzed / not available]
• Interpretation: [Hemolysis present / No hemolysis / Indeterminate / Not assessed]

DAT (Post-Reaction):

• Anti-IgG: [positive with strength / negative / not performed]
• Anti-C3: [positive with strength / negative / not performed]
• Comparison to pre-transfusion DAT: [New positivity yes/no/indeterminate / Pre-transfusion DAT not available]

Additional Testing: (Include only tests performed. State "not assessed" for indicated but unavailable tests.)

[ABO/Rh recheck, antibody screen/identification, crossmatch, eluate, hemolysis markers, urine hemoglobin, blood cultures, IgA level/anti-IgA, and other relevant tests with results as applicable]

Impression

[Brief 1–3 sentence summary integrating clerical check, hemolysis assessment, DAT, and additional results]

• Reaction Type: [Per institutional hemovigilance categories]
• Timing: [Acute / Delayed]
• Severity: [Per institutional/NHSN definitions]
• Imputability: [Definite / Probable / Possible / Unlikely / Not assessable]

(If reaction type not definitively established, note leading differentials and what information would resolve uncertainty. Do not infer negative conclusions without supporting evidence; use "not assessed" when applicable.)

Recommendations and Follow-up

Transfusion guidance: [Actionable recommendations for future transfusions with rationale—include antigen-negative requirements, product modifications, premedication, infusion rate adjustments, monitoring requirements as applicable]

Notifications completed: [Treating clinician, Transfusion Medicine medical director, blood supplier if applicable, incident reporting system if applicable—include date/time and by whom] (If notification status cannot be confirmed, document responsible party for follow-up per policy.)

Pending results: [List pending tests with expected availability and plan for addendum]

EHR updates: [Transfusion reaction flags, antibody history entries, other alerts—include completion status]