The documentation required at each stage of the transfusion process should be kept to an essential minimum and, whether hard copy or electronic, be ‘user-friendly’ to encourage compliance by busy clinical teams. Combined transfusion prescription and monitoring charts or care pathways can be used to record the information and provide a clear audit trail. The development of standardised transfusion documentation in the UK has the potential to reduce errors by clinical staff moving between hospitals. All transfusion documentation should include the minimum patient identifiers. Documentation in the clinical record should include:
- The reason for transfusion, including relevant clinical and laboratory data.
- The risks, benefits and alternatives to transfusion that have been discussed with the patient and documentation of consent (see below).
- The components to be transfused and their dose/volume and rate.
- Any special requirements, such as irradiated components.
- Details of staff members starting the transfusion.
- Date and time transfusion started and completed.
- Donation number of the blood component.
- Record of observations made before, during and after transfusion.
- Management and outcome of any transfusion reactions or other adverse events.
- Whether the transfusion achieved the desired outcome (e.g. improvement in symptoms, Hb increment).