Title: Transfusion Medicine Request Form

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Referenced in L.02.044 Transfusion Medicine Workflow, L.02.047 Emergency Release, and L.02.048 BBCS Downtime-Transfusion Medicine.

Compatibility Clients Reference Clients

(Surgery Centers and Rehabilitation Facilities) (Hospitals)
Testing Panels
Testing  Complete Antibody Identification (may
 Type and Screen include ABO/Rh, antibody screen, panel, DAT, elu-
 Type and Crossmatch tion and/or antigen typing as required)
Products  ABO/RH Discrepancy Workup (may in-
clude antibody screen, panel, DAT, elution and/or
 Red Blood Cells (quantity) antigen typing as required)
 Autologous Individual Tests
 Directed  Antibody Panel
 Therapeutic Platelet Dose (quantity)  DAT (polyspecific, IgG, and complement)
Priority:  STAT  ASAP  Routine  Elution  Adsorption
Special Patient Requirements  Neutralization  DTT Screen
 CMV=  Irradiated Priority:  STAT  ASAP  Routine
Sample Requirements Products:  Red Blood Cells (quantity)
Two EDTA samples (additional samples may be Sample Requirements
requested if initial testing is positive). The following
Sample volume requirements vary with the testing
information MUST be on every sample sub- requested. Please contact the Laboratory before
mitted for testing: sending samples for testing to ensure volume of
Patient’s full name sample is sufficient. At a minimum, samples must
MR# or SS# be labeled with:
Typenex # (Blood bank wristband number) Patient’s full name
Date/Time collected Hospital ID#, MR#, DOB or SS#
Initials of person collecting samples Date of Collection

Patient Information
Ordering Facility:

Patient
Last: First:
Name

Social Security Number: Armband (Typenex) Number:

Medical Record #: Date of Birth:

Sample Collected (date/time/initials):

Date/Time of Transfusion/Surgery:

F.0495.11
 Title: Transfusion Medicine Request Form
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Clinical Information
Diagnosis:
Hemoglobin: Hematocrit: Pregnancy History: Yes No
Date(s)/location(s)/of transfusion(s) and Component(s) transfused:

Transfusion History:
Yes No
If yes, please explain:
History of Adverse Reactions?
Yes No
Additional Information:

Current Testing Results (For Reference Clients Only)

ABO/Rh Antibody Screen Tube Gel

DAT
Tube Method Gel Method Method
IS 37° AHG Method Polyspecific
Screen Cell I AHG
Screen Cell II Anti-IgG
Screen Cell III Anti-C3b, -
*Auto Control C3d

*If routine testing doesn’t include an auto control, please perform a DAT prior to sending samples.
Please send a copy of current testing results with samples.

For We Are Blood use only:

Time sample/request received:

Results Communication (date/initials):

Reviewed by: ___________________________

F.0495.11