Center Information:
Subcenter:
Inland Northwest Blood Center
Inland Northwest Blood Center
210 W. Cataldo Ave.
Spokane, WA 99201
Transfusion Services Order
Transfused or pregnant
within last 3 months?
Last Name
First Name
Date of Birth
Gender
MI
M
No
F
Diagnosis
Yes
If yes, date_____________
Race__________
Facility Patient ID #
NA
Medications
Unknown
Specimen Requirements: 7 mL Purple Top (EDTA)
No Red Top Serum Separator
Ordering Physician
Ordering/Transfusion Facility
Facility Address
Specimen Collection Date/Time
Facility Phone
Phlebotomist ID
Testing Requested
Component And Quantity Requested
Special Instructions
______Leukoreduced RBC
Irradiated
Washed*
______Pediatric Leukoreduced RBC
(volume needed_________________)
CMV Negative
Specific Hct*
______ Apheresis Platelet(s)
Volume Reduced
Autologous
______ Plasma (volume needed_______________)
______ Cryoprecipitated, AHF
HLA Matched
Directed
Order Status
STAT
BBID Sticker
Type and Crossmatch
Type and Screen
Blood Type
DAT
Draw and Hold
RhIG Evaluation
Additional Crossmatched Units
Antibody ID
Titer
Antibody Screen
Other
Received by TS
Patient Information
ASAP
Routine
Sickle Cell Negative
______ Pediatric Platelet (volume needed_________)
______ Other (specify)_________________________
Date/Time needed
*Consult with Transfusion Service for Availability
Pretransfusion Criteria (Indicate all that apply)
eTS 003 (Rev. 7)
SVC010
PLASMA
CRYOPRECIPITATED, AHF
Fibrinogen Level
PT
PTT
INR
Diffuse microvascular
Patient bleeding or preoperative
bleeding and fibrinogen
with an INR > 2.0 or PT/PTT > 1.5
< 100 mg/dL
Coag Factor deficiencies planned/ surgery
Hemostasis required
Rapid reversal of Warfarin effect
(Other therapies not
available or working)
TTP
Other (specify)
Massive transfusion
HCLL Accession
Accession ##
HCLL
PLATELETS
Current Platelet Count______________
Platelet count of 20,000/uL or less (outpatient)
Pre-Surgery (anemia)
Platelet count of 10,000/uL or less (inpatient)
Hemoglobin
Platelet count of < 50,000/uL, bleeding
(< 7 g/dL or Hematocrit < 24%)
or surgery in < 24 hours
Symptomatic anemia
Platelet dysfunction and bleeding/
Active bleeding/Acute blood loss
planned surgery
Platelet count < 50,000 uL after RBC
Other (specify)______________
transfusion due to blood loss
Other (specify)_____________________
HCLL Accession #
RED BLOOD CELLS
Current Hgb or HCT
Fibrin glue
These pretransfusion criteria are based on current evidence-based medical guidelines. Transfusion outside of these parameters is at the discretion of
the ordering physician and should be based on the patient's clinical signs and symptoms. Medical Director consultation is available upon request.