What information must be recorded in the admission note for a patient (medical record number, age, gender) receiving a blood transfusion (e.g., for symptomatic anemia, active bleeding, or pre‑operative preparation), including blood component type and volume, transfusion start and end times, blood bank unit identification numbers, pre‑transfusion type‑and‑screen or cross‑match results, consent and checklist completion, baseline and interval vital signs, pre‑medication and its indication, post‑transfusion vital signs and clinical response, any adverse reaction with its management, and the clinician’s signature and designation?

Blood Transfusion Documentation Requirements for Admission File

All blood transfusions must be documented in the patient record with 100% traceability as a legal requirement, including patient identifiers, blood component details, unit identification numbers, pre-transfusion compatibility testing, consent documentation, vital signs monitoring, and clinician signature. 1

Essential Patient Identification Elements

Document the following four core identifiers for every transfusion:

• First name 1
• Last name 1
• Date of birth 1
• Medical record number (patient identification number) 1

These identifiers must match exactly between the patient's wristband, the compatibility label on the blood component, and the prescription. 1

Blood Component Specification

Record the following details for each unit transfused:

• Blood component type (e.g., packed red blood cells, fresh frozen plasma, platelets, cryoprecipitate) 1
• Volume of each component 1
• 14-digit component donation number (or batch number for coagulation factors) 1
• Blood group of the component 1
• Expiry date and time 1

Pre-Transfusion Testing Documentation

Document the compatibility testing performed:

• Type-and-screen or cross-match results 1
• ABO blood group confirmation 1
• Presence of any irregular antibodies 1
• For emergency transfusions: specify if un-crossmatched group O Rh-negative, un-crossmatched ABO group-specific, or fully cross-matched blood was used 1

Consent Documentation Requirements

Valid consent must be documented when blood transfusion is anticipated, ideally during pre-assessment before surgery. 1, 2

Record the following consent elements:

• Documentation that the discussion occurred regarding risks, benefits, and alternatives 2, 3
• Patient's agreement to the intervention 2
• Patient's questions and responses given 2
• Any specific restrictions or refusals (e.g., religious objections to certain components) 2
• Confirmation of patient capacity to provide informed consent 2

Common pitfall: In 75% of cases, physicians fail to document that any discussion occurred regarding transfusion risks, benefits, or alternatives. 3 Ensure explicit documentation of the informed consent conversation.

Vital Signs Monitoring Schedule

Document vital signs at the following mandatory time points:

• Pre-transfusion baseline: heart rate, blood pressure, temperature, respiratory rate 1, 4
• 15 minutes after transfusion start (critical early detection window) 1, 4
• At completion of transfusion 1
• 15 minutes post-transfusion 1

For massive transfusion or high-risk patients, document:

• Central venous pressure monitoring 1
• Urine output (aim >30 mL/h) 1
• Repeat vital signs every 4 hours or after one-third blood volume replacement 1

Transfusion Timing Documentation

Record precise timing for traceability:

• Date and time transfusion started 1
• Date and time transfusion completed 1

Critical requirement: Red cell transfusions must be completed within 4 hours of removal from the blood fridge. 1

Pre-Medication Documentation

If pre-medication is administered, document:

• Medication name and dose (e.g., diphenhydramine, acetaminophen) 4
• Indication for pre-medication (e.g., history of allergic reactions, febrile reactions) 4
• Time of administration relative to transfusion start 4

Post-Transfusion Clinical Response

Document the patient's response to transfusion:

• Post-transfusion vital signs (heart rate, blood pressure, temperature, respiratory rate) 1, 4
• Clinical improvement (e.g., resolution of tachycardia, improved oxygen saturation, symptom relief) 4
• Laboratory response if applicable (e.g., hemoglobin increment, platelet count increase) 1

Adverse Reaction Documentation

If any adverse reaction occurs, document immediately and comprehensively:

• Type of reaction (e.g., febrile non-hemolytic, allergic, anaphylaxis, TACO, TRALI, acute hemolytic) 1, 4
• Time of onset relative to transfusion start 1, 4
• Signs and symptoms (e.g., fever >1°C increase, tachycardia >110 bpm, hypotension, rash, dyspnea, back pain) 1, 4
• Management provided (e.g., transfusion stopped, epinephrine administered, antihistamines given, fluid resuscitation) 1, 4
• Notification to transfusion laboratory with date and time 1, 4
• Blood unit and administration set sent for investigation 1, 4

Common pitfall: Misidentification is the most common transfusion risk and must be documented as excluded through proper bedside checking. 1

Clinician Signature and Designation

Every transfusion record must include:

• Signature of the clinician who prescribed the transfusion 1
• Signature of the clinician(s) who performed the bedside check 1
• Professional designation (e.g., attending physician, resident, registered nurse) 1
• Date and time of documentation 1

For massive transfusion: A designated coordinator should be nominated to take responsibility for overall communication and documentation. 1

Location of Documentation

Transfusion documentation may be recorded in:

• Anaesthetic chart (for intraoperative transfusions) 1
• Drug/fluid prescription chart 1
• Separate transfusion record in the patient's notes 2
• Electronic transfusion management system (preferred method) 1, 5

Post-Discharge Requirements

Before discharge, document that:

• The patient was informed they received blood components (otherwise they will be unaware) 1
• The patient was informed this removes them from the donor pool 1
• The general practitioner will be notified of the transfusion 1

Common pitfall: Only 12% of charts include documentation that the patient was subsequently told what blood components were given to them. 3 Ensure this conversation and documentation occur before discharge.

Special Populations

For transgender patients of childbearing age: Report transgender status to the hospital's blood transfusion service with patient consent to ensure appropriate blood products (e.g., Rh-negative for those retaining uterus/ovaries). 2, 6

For unidentified patients: Document the unique identification number assigned (e.g., "unknown male #12345") and note when identity becomes known with new sample collection. 1

Traceability and Legal Requirements

Traceability records must be maintained for 30 years as a statutory requirement. 4 Chart records should match transfusion medicine records; however, studies show only 60.6% concordance, with the most common error being incorrect blood unit identification numbers. 3