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Nursing:
doi: 10.1097/01.NURSE.0000383460.71153.2e
Department: FOR THE RECORD

Documenting transfusion therapy

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A BLOOD TRANSFUSION is an I.V. infusion of whole blood or a blood component or derivative, such as red blood cells, plasma, or platelets, to replace deficiencies or losses including those resulting from surgery, trauma, or disease. No matter which blood product you administer, you're required to follow organizational policies and procedures and practice guidelines to prevent potentially fatal errors.

Begin by verifying the prescription for transfusion therapy, as well as verifying that informed consent has been obtained and documented in the patient's medical record.

Your documentation related to transfusion therapy should include:

* verification of the prescribed blood product and blood product compatibility

* verification of appropriate clinical indication for the transfusion

* the vascular access device used for the transfusion therapy, including type, size, access site, and condition and appearance of vascular access site

* verification of proper patient identification

* the date and time of transfusion, type of blood product administered, in addition to the volume, infusion rate, and time of initiation and completion of transfusion

* any medication administered, including premedication (if I.V. drugs are required during transfusion, another I.V. site is required)

* the use of special equipment, such as a blood warmer or specialized blood filters

* the patient's clinical status throughout the transfusion therapy, including patient assessment data such as vital signs and lung sounds

* the patient's response to therapy including any complications or adverse reactions, treatment required, and response to that treatment; the amount of blood transfused and the return of the unused portion to the blood bank

* patient education provided, as well as the patient's understanding of information provided.

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RESOURCES

Chart Smart: The A-to-Z Guide to Better Nursing Documentation. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.

Infusion Nurses Society. The Infusion Nursing Standards of Practice. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.

Lynn P. Taylor's Clinical Nursing Skills: A Nursing Process Approach. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.

© 2010 Lippincott Williams & Wilkins, Inc.

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