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Form Blood Requisition

This document is a requisition form for blood or blood components from the Blood Storage Centre at AIIMS Patna. It requires information about the patient, their diagnosis, blood type if known, the reason for transfusion, and the type of blood product required. It specifies that blood samples must be properly labeled with at least 3-5ml in a plain vial and 2ml in an EDTA vial. The form must be signed and have no blank sections or the samples will be unacceptable. The receiving center information and crossmatch results will be filled in, with the technologist and medical officer signatures required.

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shubham kumar ram
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2K views2 pages

Form Blood Requisition

This document is a requisition form for blood or blood components from the Blood Storage Centre at AIIMS Patna. It requires information about the patient, their diagnosis, blood type if known, the reason for transfusion, and the type of blood product required. It specifies that blood samples must be properly labeled with at least 3-5ml in a plain vial and 2ml in an EDTA vial. The form must be signed and have no blank sections or the samples will be unacceptable. The receiving center information and crossmatch results will be filled in, with the technologist and medical officer signatures required.

Uploaded by

shubham kumar ram
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Blood Requisition Form
  • Cross Match Record

Blood Storage Centre, AIIMS, Patna

Requisition Form-Whole Blood/ Packed Red Blood Cell/ Component

* 3-5ml Sample in plain vial and 2ml in EDTA vial & the vial(s) must be labelled with properly & clearly.
*Requisition form and sample with discrepancy are UNACCEPTABLE.
*This form will NOT be accepted if it is not signed or any section is left blank.

Patient’s Name …………………………..Evolko ID…………………Age………M/F


Diagnosis……………………………Faculty Incharge………………………Ward…..
Blood Group (if known)…………………Rh……………….
Indication for Transfusion:
( ) Bleed ( ) Exchange transfusion*(TSB value_____) ( ) Trauma
( ) Dialysis ( ) Anaemia ( ) Surgery ( ) IUT
( ) Burn
*For exchange transfusion please send mother’s sample also (3ml in plain vial)
Pre- transfusion Hb: ________________gm/dl (If known).
Quality of blood unit(s) required:
PRBC ( ), FFP ( ), CRYO ( ), PLASMA ( )
Previous Transfusion ( ) YES ( ) NO. Unit nos.__________________________
(If yes, please attach completely filled & duly signed reaction form) Adverse reaction, if any ( ) YES ( ) NO.

Certified that I have personally collected the blood sample after identification of Patient’s Name, Evolko ID etc. I have
explained the necessity of blood transfusion and the risks associated with it to patient/ relatives.
( ) Routine (AHG cross match technique)
Time………………AM/PM Residents signature……………………….JR/SR……………
Date………………… Name……………………….Contact Number……………..

Space to be used by the Blood Storage Centre, AIIMS, Patna

Received at …………..AM/PM Date…………Patient’s Identification matched with sample/vial (YES/NO)


Signature of staff on Reception…………………………………
Patient’s Preliminary Blood Group: ……………………………….……..
Cell Grouping
Signature of Medical Technologist: ………………………………………
Anti A Anti B Anti AB Anti D

Remark of Resident for the case:

Signature/Date/Time*……………………………
(* Time is essential in cases put up for emergency cross match).

* Note: This Requisition form will not accepted in the outside AIIMS, Patna.
CROSS MATCH RECORD
Cell Grouping Serum Grouping Blood Group
Anti A Anti B Anti AB Anti D A Cell B Cell O Cell ABO Rh(D)

Auto Control: Positive/ Negative


For PRBC/WB
SI. Blood Blood Group Quantity Immediate spin Saline AHG cross match Compatible
No Unit No (ABO & Rh) of PRBC cross match at RT (37`C)
Major Minor Major Minor Yes No

For Component (s)


SI No Component Unit No Tube No Blood Group Quantity Type of Component (s)

Date: - ___/____/____ Signature of Technologist_________________


Time:-____:_____AM/PM

Date: - ___/____/____ Signature of Medical Officer/SR on duty______________


Time:-____:______AM/PM

* Note: This Requisition form will not accepted in the outside AIIMS, Patna.

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