Date
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Indication for Transfusion:
Thrombocytopenia (low platelet count) with bleeding risk (e.g., active bleeding, high-risk surgery)
Prophylaxis to prevent bleeding in thrombocytopenic patients undergoing invasive procedures
Pre-Transfusion Assessment:
Platelet count: [value] (/uL)
Bleeding time: [value] (if measured)
Blood type: [ABO type], Rh factor
Platelet crossmatch: [performed/not performed], result (if performed)
Vital signs: BP [value] / [value] mmHg, Pulse [value] bpm, Respiratory rate [value] bpm, Temperature [value] °C
Allergies: [list allergies, if any]
Informed consent obtained for transfusion (yes/no)
Transfusion Details:
Blood product transfused: [Number] units of platelets, [Blood product name] (e.g., apheresis platelets, random donor platelets)
ABO type and Rh factor compatibility: [compatible/incompatible]
Platelet count on transfused unit(s): [value] (/uL)
Blood bank verification of blood product: verified (yes/no)
Transfusion start time: [time]
Transfusion end time: [time]
Transfusion site: [IV site location]
Transfusion Reaction Monitoring:
Vital signs monitored every [frequency] minutes during transfusion and for [duration] minutes after completion.
Documented signs of transfusion reaction: [list any observed signs, if none, document “no signs of reaction observed”]
Post-Transfusion Assessment:
Platelet count: [value] (/uL) drawn [time] post-transfusion (if obtained)
Vital signs stable (yes/no)
Bleeding (continued/stopped)
Plan:
Continue monitoring for signs of transfusion reaction for [duration] hours.
Repeat platelet count as needed to assess response to transfusion.
Consider further management based on clinical response and ongoing bleeding risk.
Note: This is a template and may need to be modified based on the specific situation. Additional information may be added as needed.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment.