Reporting transfusion reaction investigation results

[knelson]

Hi, everyone!  We are revamping our transfusion reaction investigation procedure, going from a totally paper report to SoftBank entry/reporting.  What do you report to the patient's chart?  Do you report everything you have done (clerical check, DATs, hemolysis check, etc.) or just the pathologist's findings/interpretation?  I don't think most physicians care about all that is done in the Lab, but only want to know the final interp.  Thank you!

[pstruik]

You are right, of course, that the physicians aren't that interested in the details.

 

In my lab we used to report everything with an emboldened interpretation/conclusion section at the end which was especially useful when eg we found patients who had an unexpectedly positive DAT which only came to light when testing pre- and post-transfusion samples whilst investigating a suspected reaction.

 

 

You are raising that most central question which we don't ask often enough - what is the purpose of this report ?

[tbostock]

We also have SoftBank and we send all tests over to our HIS.  However, I agree that most physicians only want to see the interp.

[Malcolm Needs ☆]

I agree, but there is a major difference between a delayed haemolytic transfusion reaction and a delayed serological transfusion reaction.

The findings within the Pathology Laboratories, and in particular, the Transfusion Laboratory, may be identical, but the clinical sequelae are quite different, in that the first is clinically significant and the second is not.

Therefore, unless we encroach upon the physician's area (i.e. diagnosis), we cannot interpret. We can only say that our findings are consistent with...........................

[Liz0316]

We report all the tests within the battery. The MD interpretation remains pending until the reaction is reviewed by the medical director. I then type in a brief interpretation (no evidence of a hemolytic transfusion reaction, or urticarial, per Dr. xxx,  etc..)  and add "see charted report" if my medical director get wordy. All paperwork is copied and sent for charting, including the medical directors written interpretation.

[Sandy L]

Our Transfusion Reaction investigation is similar to Liz D's.  We do report the details of our investigation, .ie. Clerical Check, what type of product, ABO/Rh of the patient and unit (from the clerical check), unit ISBT DIN, DAT, visual hemolysis check, post sample repeat ABO/Rh type.  Once that is resulted the reaction goes to the Medical Director for the Interpretation (what really matters to the physicians).  The Medical Director can select form a variety of "canned" interpretations or write a custom interpretation.

[David Saikin]

We report the unit number, symptoms and the pathologist's interpretation

[tkakin]

We report the interpretation only.