CHART SMART

Documenting a
transfusion reaction
IF A PATIENT develops a transfusion reaction, your
first steps are to immediately stop the blood transfu-
sion, disconnect the blood tubing, begin an infusion of
0.9% sodium chloride solution through new tubing to
maintain venous access, and notify the patient’s health
care provider and blood bank. Follow up with appropri-
ate interventions. Here’s how to document your care.
Document the time and date of the reaction, type and
amount of infused blood or blood product, time you start-
ed the transfusion, and time you stopped it. Also record
the patient’s signs and symptoms in the order of occur-
rence, his vital signs, name of the health care provider
notified, the time you notified him, any urine or blood
specimens sent to the lab for analysis, any treatment
given, and the patient’s response to it. Indicate that you
sent the blood transfusion equipment and all related
forms and labels to the blood bank. Along with an inci-
dent report, some health care facilities also require you to
complete a transfusion reaction report and send it to the
blood bank.
When you document your follow-up care, indicate the
time for each note you write. Avoid block charting (writing
one note to cover a long block of time). It could be used
against you to imply that you didn’t provide timely nursing
care or act quickly enough when your patient developed a
problem. Specify the time of each sudden change in the
patient’s condition, significant events, prescriber notifica-
tion, and your nursing actions.
Here’s a better way to document the information above:
3/2/05 0550—One unit of PRBCs hung per
Dr. Stein’s order. Infusing well via L hand
18-gauge I.V. access. A. Cook, RN————-----
3/2/05 0600—Pt. complained of general-
ized pruritus; no urticaria noted; VS
unchanged from baseline. Blood transfusion
immediately stopped. Dr. Stein notified and
50 mg diphenhydramine given P.O. as
ordered. A. Cook, RN——————-------------
3/2/05 0615—Pt. resting comfortably; itch-
ing resolved. Transfusion resumed per Dr.
Stein. A. Cook, RN———————-------------
Following these guidelines can help keep you on solid
ground legally if your patient develops a transfusion
reaction.
Source: Chart Smart: The A-to-Z Guide to Better Nursing Documentation, Springhouse Corp., 2002.

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