We are looking to streamline our documentation for patients who are receiving Massive Transfusions.  Currently Nursing documents each unit given individually on its own Blood Administration Form in Cerner.  The form is 3 parts that includes pre-vitals, Unit info and patient verification, start-stop times, volume infused, post reactions or lack of.  Does anyone document differently when using MTPs? What is the minimum Nursing documentation required for transfusion?  We were thinking of making a form that includes multiple donor numbers. Do the start and stop times need documented per unit or could we do it as a group? We are level 3 trauma center and rarely get patient's that require MTPs.   Looking for a good method in case we need to stabilize in OR/ER before transporting.

If I was inspecting, I could live with  start times only as long as it is part of your MTP protocol.

Definitely want to see the unit #s transfused.  I think it is too much to expect during these crisis situations to get stop times; usually the rbcs are pushed as fast as they can.

Once it calms down, I'd expect the proper documentation.

 

I would agree with David. It is too much to expect to get the same kind of documentation during a MTP protocol that you get during a 'normal' transfusion. One thing that nursing staff does at my facility is to designate the resource coordinator to sure as the recorder for everything that goes on during a MTP or Code. If he/she isn't available, someone else will fill that role. That person can document provider orders, med administration, blood products, etc.

two signature, and reaction for all unit and start time for first unit and end time for last unit.