During a recent inspection, the surveyor wanted to see the results of the transfusion reaction workup on the patient's chart. We had the pathologist's interpretation on the chart, but not the actual results of the workup. She wanted to see that on the chart. Just wondering what everyone else is doing, are you just placing the interpretation on the chart or is the entire workup on the chart including clerical check, hemolysis, DAT, etc.

We do the whole nine yards.  Pathologist report is computerized. BB data is on a manual form scanned into the EMR.

LOL you must have the same inspector we just had. We had the test results (yes, we result the clerical, DAT, etc) and the pathologist's interpretation but it was not electronically attested by him.

While we would have all the data on the computer, including comments specific for resulting DATs and things for a possible RXN workup, the pathologist actually signs another form. 

 

After manually entering info into that form, it includes more detail about the event and extra testing, if any.  That form then goes into the EHR,

 

Scott

We have a paper worksheet that we result testing on and it is reviewed/signed by the pathologist with his/her impressions. That report stays in blood bank, though we used to scan it into the EMR. We have recently added a report form in the LIS that has drop-down options and free text boxes to report that same information for the EMR - no worries about crossouts and bad handwriting. That LIS report has a comment that says it is a preliminary report - see pathologist final report. The pathology report sounds similar to what Scott described - free text entries into the same system pathology uses for all their reports and it goes into the EMR under the physician consultation tab with an electronic signature. Our policy says that the preliminary report must be finalized within 24 hours (usually takes only an hour or two in actual practice) and it includes documentation that the pathologist has been consulted and the patient's nurse has been notified of preliminary findings.

 

I also compile a running report for Quality that summarizes symptoms and findings for all suspected reactions.

 

We've made it through recent JC and CAP inspections with no comments made, so hopefully we're on the right track.

We have a test profile that includes clerical check, exam for hemolysis, DAT, typing, pathologist interp. We answer the first 4, the pathologist the last. Goes on the chart and in the EMR like any test.

We do the whole thing. Being as we use Meditech we have a test built for the transfusion reactions. It includes the retypes, the rescreens, the DATs, etc. Plus it includes the clerical checks and the interp.

Same as Dr. Pepper, we have an order for Transfusion Reaction Investigation that has fields to result the unit DIN and product component type, clerical check, visual hemolysis, DAT, ABO/Rh.  We result those and there is also a pathologist's interpretation.  We also have a worksheet that we retain internal to the blood bank that has details like signs and symptoms of reaction, when and who notified us, etc.

I should add that our test profile also includes the unit DIN and amount returned. We also have a blood culture reflexed.

Do you mean like this?

Transfusion_Reaction_Form.doc

Edited October 16, 20159 yr by Auntie-D

We do the whole nine yards.  Pathologist report is computerized. BB data is on a manual form scanned into the EMR.

 

Same here.