3.5 Documentation

All aspects of the administration of blood products are documented. Documentation must minimally include the following components:

• Date and time that the blood transfusion began
• Name of the second nurse who did the two-person verification process
• Name and amount of the specific type of transfusion (for example, 1 unit of packed red blood cells)
• Blood product number
• Confirmation that written informed consent was obtained
• Indications for the transfusion
• Premedications administered
• Donor identification number
• IV site location
• Size and gauge of IV catheter access
• Duration of the transfusion
• Vital signs before, during, and post-transfusion according to agency policy
• Pre- and post-transfusion focused assessments (lungs, heart, etc.) according to agency policy
• Indication that the client was informed about when and why to contact the nurse after the initial 15-minute monitoring period
• Amount of normal saline solution infused
• Client response to the transfusion
• If a transfusion reaction occurs:
  • Name of the provider notified
  • Time of notification
  • Interventions performed
  • Client’s response to those interventions.
• Any teaching provided to the client and family, including their understanding of the teaching and any follow-up that was needed

Sample Documentation:

12/7/20XX 1445

Transfusion of one-unit (250mL) packed RBCs started at 1445 via 20-gauge saline lock in the right forearm. Unit product #G901 301 000 482. Blood product and client identification verified with Jane Smith, RN. Informed consent signed and in client chart. Infusion indication: symptomatic anemia with hemoglobin level at 7.4 mg/dL. Client verbalizes understanding of the reason for transfusion and the need to inform RN as soon as possible if any symptoms develop during transfusion. Microaggregate Y-tubing system attached to packed red blood cells and 0.9% normal saline. Pre-transfusion vital signs and assessments: T 98.2 F (temporal), HR 88 bpm, RR 20, BP 112/68, SpO2 97% on room air, lung sounds clear, regular heart rate with no extra sounds.

1500: Stayed with client for the first 15 minutes of initiation. Client tolerated infusion without any new or adverse signs or symptoms.

1715: Unit (250 mL) was infused within 2.5 hours, with 50 mL of normal saline 0.9%. Time of completion: 1715. Post-transfusion completion vital signs and assessments: T 97.6 F (temporal), HR, 78 bpm, RR 22, BP 128/72, SpO2 97% on room air, lungs sounds clear, regular heart rate with no extra sounds. IV site intact and patent without signs of phlebitis or infiltration. Client appears comfortable and denies discomfort. 

Manuel Roberts, RN