Download Patient History Check - Health and Community Services

STANDARD OPERATING PROCEDURE FOR
PATIENT HISTORY CHECK
Standard Operating Procedure for
Patient History Check
Provincial Blood
Coordinating Program
1.0 Principle
1.1
To review current patient results with previous records for possible
discrepancies to check for special instructions or comments that have been
previously documented. This will assist in the selection of appropriate blood
products for transfusion/infusion.
2.0 Scope and Related Policies
2.1
A patient history check shall be preformed on specimens received in the
transfusion medicine laboratory. This history check shall be documented.
2.2
Previous results must be compared with current results and discrepancies
resolved.
2.3
Previous admission records and/or previous patient history data alone shall
not be used to determine the patients ABO and Rh type.
2.4
There shall be an established hospital policy regarding patient history check
when Laboratory Information System (LIS) is unavailable.
3.0 Specimens-N/A
4.0 Materials
Laboratory Information System (LIS)
Requisition or electronic order entry
5.0 Quality Control – N/A
_______________________________________________________________________
This document may be incorporated into each Regional Policy/Procedure Manual.
NL2010.013
Version: 3.0
Effective Date: 2014-08-25
Page 2 of 6
Standard Operating Procedure for
Patient History Check
Provincial Blood
Coordinating Program
6.0 Process Flowchart
6.1
Process Flowchart
Check for previous
patient record
Was previous
record found?
NO
Document patient
information in LIS or on
patient requisition
YES
Verify patient
information
Was
discrepancy
identified?
YES
Resolve
discrepancy
NO
Complete required
tests
Compare current
and previous
records
Is there a
discrepancy?
YES
Resolve
discrepancy
NO
Document
comparison was
performed
_______________________________________________________________________
This document may be incorporated into each Regional Policy/Procedure Manual.
NL2010.013
Version: 3.0
Effective Date: 2014-08-25
Page 3 of 6
Standard Operating Procedure for
Patient History Check
Provincial Blood
Coordinating Program
7.0 Procedure
7.1
Check for previous patient record by using MCP number or unique
identification number.
7.2
If a previous record is found:
7.2.1
Compare and verify patient information. (Name, date of birth and
identification number) between the requisition and information on
file. Any discrepancies must be resolved.
7.2.2
Complete current test and compare results with previous records
for the following records:





7.2.3
7.3
Previous ABO and Rh groupings
Complications in determining blood type
Clinically significant red cell antibodies
Adverse reactions to a previous transfusion/infusion
Special requirements, if applicable (e.g. CMV negative or
irradiated)
This comparison must be documented.
If no previous history is found for the patient, all pertinent information
regarding patient transfusion history must be documented on at least one of
the following:
 LIS (i.e. Meditech, Medical Records, or other information
system)
 Patient’s requisition
8.0 Reporting—N/A
_______________________________________________________________________
This document may be incorporated into each Regional Policy/Procedure Manual.
NL2010.013
Version: 3.0
Effective Date: 2014-08-25
Page 4 of 6
Standard Operating Procedure for
Patient History Check
Provincial Blood
Coordinating Program
9.0 Procedural Notes
9.1
If a clinically significant red cell antibody(s) is detected in the patient
sample or there is a history of an antibody in the patients file, select antigen
negative red cell components for transfusion.
9.2
There must be a specific facility procedure for a computerized history
check.
.
10.0 Records Management
10.1 The following information should be kept indefinitely:
 Recipient transfusion data file in the Transfusion Medicine Laboratory
 All serologic test records
 Serious adverse reaction
 All information required for look back or trace back purposes
10.2 All transfusion records in the recipient’s medical chart shall be retained in
accordance with health care facility policy.
10.3 Request form for serologic tests shall be retained for one month.
10.4 Documentation of staff training and competency must be kept for a
minimum of ten years .This shall include the signature of the person,
identification and initials.
_______________________________________________________________________
This document may be incorporated into each Regional Policy/Procedure Manual.
NL2010.013
Version: 3.0
Effective Date: 2014-08-25
Page 5 of 6
Standard Operating Procedure for
Patient History Check
Provincial Blood
Coordinating Program
References
Canadian Standards Association. (2010). Blood and blood components Z902-10.
Mississauga, ON: Author.
Canadian Standards for Transfusion Medicine. (2011). Standards for hospital
transfusion Services. (Version 3.0). Ottawa, ON: Author.
Manitoba Provincial Blood Coordinating Office. (2007). Manitoba transfusion
quality manual for blood banks. (Version 2.0). Winnipeg, MB: Author.
Roback, J., Grossman, B., Harris, T. & Hillyer, C. (2011). Technical manual. (17th
ed.). Bethesda, Maryland: AABB.
Transfusion Ontario Programs Ottawa Office. (2009). Ontario regional blood
coordinating network standard work instruction manual. Ottawa, ON: Author.
_______________________________________________________________________
This document may be incorporated into each Regional Policy/Procedure Manual.
NL2010.013
Version: 3.0
Effective Date: 2014-08-25
Page 6 of 6