Blood products are recorded the same way as any other medication, with one extra panel for the details a transfusion needs and one procedure that gets added for you.

Before you start: You need an open PCR on the Timeline tab.

Record the transfusion

  1. On the Timeline tab, click Entry, then click Medication.
  2. Pick the product from the medication list. Seven blood products are available to every agency: Whole blood, Packed red blood cells (RBC), Plasma, Platelets, Cryoprecipitate, Albumin, and Blood product. Each one has a blood drop next to it in the list so you can pick it out quickly.
  3. Fill in the usual medication fields: time, dose, dosage units, route, and the patient response.
  4. A Transfusion Details panel appears as soon as you pick a blood product. Fill in what you have.
  5. Click Save.

What is in Transfusion Details

  • Unit Number and Donor Number — the identifiers printed on the bag.
  • Blood Facility ID — the code for the blood bank that supplied the unit.
  • Donor Blood Type — one field for the whole type, so you pick O- rather than picking O and negative separately.
  • Expiration Date.
  • Equipment Used — blood warmer, pressure infuser cuff, infusion pump, gravity, or pushed.
  • Indication — why the patient needed it. You can pick more than one.
  • Patient Response — you can pick more than one, and None is an answer worth recording rather than leaving blank.
  • Action Required — what you did if the patient reacted.
  • Status at Transfer of Care — whether the transfusion finished, was still running at handoff, or was stopped.

The Verification section

Blood is checked by two people before it goes in. The Verification section records who did what:

  • Who gave the blood — your initials.
  • Who checked the unit — the second person who confirmed the unit against the paperwork, with their initials.
  • Who confirmed the patient and Second person confirming the patient — the two people who confirmed the patient's identity at the bedside.

The procedure that gets added for you

When you save a blood product, a Transfusion of blood procedure is added to the Timeline at the same time. You do not need to add it yourself, and you should not add a second one.

This happens because a transfusion has to be recorded as both a medication and a procedure. A blood product with no matching procedure, or a procedure with no matching blood product, fails the checks your state runs when the PCR is submitted. Adding both together keeps the chart clean without you having to remember it.

A few things follow from that:

  • The procedure carries the same time, crew member, and response as the medication.
  • If you give more than one unit, you still get one procedure, not one per unit.
  • You can open the procedure and fill in the rest of it, such as the vascular access site.
  • If you change the medication to something that is not a blood product, the procedure is removed again — unless you have already filled in details of your own, in which case it stays and you can delete it yourself.

An example

A trauma patient is hypotensive after a fall. You start one unit of packed red cells through a blood warmer on the way to the trauma center, and it is still running when you hand over.

Click Entry, then Medication, and pick Packed red blood cells (RBC). Enter the time you started it, dose 1, units Units, route IV, response Improved. In Transfusion Details, enter the unit number from the bag, pick O- as the donor blood type, pick Blood Warmer as the equipment, pick Massive Hemorrhage as the indication, and set Status at Transfer of Care to the option for still running at handoff. In Verification, put your initials under who gave the blood and your partner's name and initials under who checked the unit. Click Save. The medication and a Transfusion of blood procedure both appear on the Timeline.

What your state receives

Every agency records the same transfusion details. What gets sent to your state depends on what your state asks for. The product, the dose, the route, the response, and the procedure go to every state. The extra details, such as the unit number and the verification names, are sent to states that collect them, and stay on your chart for your own quality reviews everywhere else. There is nothing to configure for this.

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