Pre-Op Samples - Dcumenting Transf History

[KKidd]

How do you document a patient's history(transfusion/pregnancy) to determine when the pre-op sample should be collected? Is this form charted? Thanks!

[PAWHITTECAR]

If they wish to collect a pre-admit specimen that can be extended for >3 days there is a blood bank form that they have to fill out. The form has the questions as to if the patient has been transfused or pregnant in the last 3 months. These forms are maintained in the blood bank. We do not get this request very often maybe once or twice a year.

We had a similar form at a prior hospital as well and it was used often.

[goodchild]

We have a questionnaire form (essentially: have you been transfused, pregnant or under general anesthesia for the past three months?) that the patient fills out and signs and the phlebotomist signs as a witness. When the specimen & form show up in the transfusion service we enter a canned comment based on their answers into the specimen comments for the type and screen. The form itself is saved in our pre-in binder until their D.o.S. After that it gets held for a week and shredded. Works well, we do hundreds of them this way.

[GCH LAB RAT]

How do you document a patient's history(transfusion/pregnancy) to determine when the pre-op sample should be collected? Is this form charted? Thanks!

We also ask questions and hold the form in blood bank until surgery. I have attached a copy of the form for your review.

[bxcall1]

We don't use a specimen older that 48hrs. Meditech is set up to auto release units at 72 hrs so extending a crossmatch longer would have to be done on a case by case basis. Not worth the trouble of documenting, changing auto release, etc.

[Brenda K Hutson]

Have seen it done different ways at various places. I want to have something concrete to fall back on (whether it is a hard copy of a Form signed by the patient at the time the blood was drawn; sent to the Blood Bank; then saved there for some period of time), or whether there is a way for the person obtaining that information from the patient (RN, Phlebotomist, etc.) to document it electronically in the computer. While I prefer a method where I have an actual signature from the patient (just to cover myself), I can honestly say I have seen many instances where the patient gives erroneous information! Either because the question is not worded well so they misunderstood, and/or because they did not realize they had been transfused (which is still shocking to me in this day and age), and/or because they are confused.

Brenda Hutson, CLS(ASCP)SBB

[pbaker]

We collect pre-op specimens up to 30 days out. When they return day of surgery, there is a questionnaire completed and documented electronically by nursing asking about transfusion and pregnancy within the past 3 months. If either question is answered yes, then another TS is performed. If both questions are answered no, then we just do an ABO/Rh. Our computer builders made a test called PNEG (pretesting negative) that will allow us to crossmatch on the day of surgery specimen.

Sometimes the blood bank can determine that the questions are answered incorrectly and we follow up with the person documenting the answers. Sometimes it is the patient answering incorrectly and sometimes it is a typo. Unfortunately, there is no perfect system. We have been doing it this way for years and have had no major problems and have passed all our inspections.

[Brenda K Hutson]

That is great that you can achieve this electronically. Also, point well taken; the answers they give to those questions on the day their pre-op specimen is drawn, may not be the same when they come back (especially when you are extending a specimen out by 30 days). I think that 99% of the time we would not expect a patient who is scheduled to go to surgery in the near future, to be getting transfused between the pre-op specimen and the surgery; but it certainly can (and does) occur.

Brenda

We collect pre-op specimens up to 30 days out. When they return day of surgery, there is a questionnaire completed and documented electronically by nursing asking about transfusion and pregnancy within the past 3 months. If either question is answered yes, then another TS is performed. If both questions are answered no, then we just do an ABO/Rh. Our computer builders made a test called PNEG (pretesting negative) that will allow us to crossmatch on the day of surgery specimen.

Sometimes the blood bank can determine that the questions are answered incorrectly and we follow up with the person documenting the answers. Sometimes it is the patient answering incorrectly and sometimes it is a typo. Unfortunately, there is no perfect system. We have been doing it this way for years and have had no major problems and have passed all our inspections.

[AMcCord]

We also ask questions and hold the form in blood bank until surgery. I have attached a copy of the form for your review.

Like your form. Yours adds some good tweaks that mine doesn't have.