ST.

JAMES HOSPITAL
VQR MEDICAL FOUNDATION
Vigan City
Tel.no: (077) 674-0830
CLINICAL LABORATORY
BLOOD TRANSFUSION FORM

Name of Recipient: BATAD, CECILIA G. Ward / Room No.: 304 Date: 17-AUG-2017
Recipients Identification No.: ________ Age: 58 Sex: F Blood Type: A Rh POSITIVE

Donor No / ABO / Rh Collection Expiration Date

Source Component Date
17-5782 / MMMH & MC A RH POSITIVE WB 8-11-2017 9-15-2017
17-5775 / MMMH & MC A RH POSITIVE WB 8-11-2017 9-15-2017

Component / Blood Type Requested: A Rh POSITIVE Requesting Physician: DR. RAFANAN

( ) Whole Blood (WB) ( ) Platelet concentrate
( X ) Packed Red Blood Cells (PRBC) ( ) Cryoprecipitate
( ) Fresh Frozen Plasma ( ) Others (specify)_ ____
-
Result of Compatibility Testing: COMPATIBLE ( 3 Phases)

Crossmatching Done By: ____________________________ Date: 17-AUG-2017

Medical Technologist

( ) Emergency Testing ( ) Cross-matched:

( ) Uncrossmatched [ ] Saline Phase Only
(X) ABO / Rh Compatible [ ] Saline & Albumin Phase Only
[X] Saline, Albumin & Anti-globulin Phase

Modesty M. Alejandro-Leao,MD,FPSP
Pathologist

DONOR NUMBER BLOOD UNIT APPEARANCE OF TRANSFUSION TRANSFUSION TRANSFUSION

RECEIVED BY: UNIT CHECKED BY: STARTED BY: COMPLETE SET REMOVED
DATE / TIME DATE / TIME DATE / TIME DATE / TIME BY:
DATE / TIME
17-5782
17-5775

Remarks: ( ) Transfusion completed without immediate transfusion reactions noted.

( ) Transfusion stopped with transfusion reactions noted.
( ) Fever ( ) Nausea ( ) Flushes
( ) Chills ( ) Vomiting ( ) Rashes
( ) Others: (specify) _________________