Community Hospital Day Transfusions Booking Form

GP/Referrer to complete first two sections

Section 1 Patient details rationale and date requested
Patient name: / Date of birth:
NHS number: / Referring GP:
Area (egTown/Exmouth): / Name of GP practice:
Treatment /Transfusion requested : / Rationale for treatment:
Infection Control Alerts or any special requests : / Patients verbal consent for above treatment obtained: Yes/No
Location preference:
Sidmouth / Tiverton / Wynard Ambulatory Unit (default if no capacity for required time or if patient because of locality would prefer their transfusion at the RDE contact 01392 408609)
Date and time preference:
Referring GP to fax patient summary and input onto System 1/EMIS / Yes/No
Referring GP to fax prescription if regular medication required during the day or single administration (eg diuretics) required during transfusion. / Yes/No
Section 2 Only complete this section if a Blood Transfusion
Indication for packed red cell transfusion: / Special requirements? / Confirmation that risks of transfusion were explained:
Bleeding / Irradiated / Human Error
Symptomatic Anaemia / CMV Negative / Circulatory Overload
Top up transfusion for chronic anaemia or prior to surgery / HLA selected / Adverse Immune Responses
Transfusion Transmitted Infection
Anaemia in patient under care of haematology, oncology, radiotherapy or renal physicians / Pre-Transfusion Hb ……………...... g/l.
Date of sample ………………………………….
Other…….. / Target Hb ……………………...g/l
Signature of person taking the referral:
Print name:
Designation: / Date: / Time:
To be completed by Transfusion Team
(Please add YES/NO)
Booking form checked referral accepted
Availability checked and inputted onto booking diary and confirmed with location (if not Sidmouth)
Date and location confirmed with referrer either by email or faxingcompleted form back to referrer or by telephone.
Letter sent to patient confirming date and location
RDE notes ordered by Transfusion Team Admin Support
Prescription completed
Blood/IV Drugs egMonofer ordered

Final 10/08/2017