BICUTAN MEDICAL CENTER, INC.

191 ML QUEZON STREET, NEW LOWER BICUTAN, TAGUIG CITY

BLOOD TRANSFUSION REACTION FORM

Date Transfusion Started: ___________________
Date Transfusion Ended: ____________________
Date of BTR: _____________________________
Amount Transfused: _______________________
History of Previous Reaction: ________________
Time: __________________________________
Time: __________________________________
Time: __________________________________
No. of units Transfused: ___________________
Date and Time: ________________

CLINICAL SIGNS AND SYMPTOMS

SYMPTOMS DURING AFTER

YES NO YES NO

Hives

Pain (if Yes, Location)

Itchiness

Nausea/Vomiting

Chills

Rash

Fever

Hematuria

Others (Please indicate)

ACTION
Anti-Histamine given: _________________________ Response to Anti-Histamine: _______________________

Medicine given: ______________________________ Response to Medicine: ___________________________

COMMENTS/FINDINGS BY CLINICAL RESIDENT

Submitted by: ____________________________

Resident on Duty
(SIGNATURE OVER PRINTED NAME)
Prepared by: _____________________________ Date and Time: _____________________________
SIGNATURE OVER PRINTED NAME
REMAINING BLOOD:
Please complete the form and forward with appropriate blood specimens and used pack to the Hospital Blood Bank
IMMEDIATELY.
BICUTAN MEDICAL CENTER, INC.
191 ML QUEZON STREET, NEW LOWER BICUTAN, TAGUIG CITY