Study of Quality of Documentation of Blood Request Forms in a Tertiary Care Hospital Selvi N. Thamarai1, Prasanth B. Krishna2,*, Begum Rameejan1, Hemanathan G.1, Anusha A.S.2 1Assistant Professor, Department of Pathology, Ponnaiyah Ramajayam Institute Of Medical Sciences 2Assistant Professor, Department of Community Medicine, Ponnaiyah Ramajayam Institute Of Medical Sciences *Corresponding Address: Dr. B. Krishna Prasanth Assistant Professor & Epidemiologist, Department of Community Medicine, Ponnaiyah Ramajayam Institute of Medical Sciences, E-mail: mail2kristain@gmail.com
Online published on 16 March, 2018. Abstract Introduction Blood transfusion is an essential part of modern health care. Blood request forms are filled by residents and consultants of respective departments and sent to the blood bank. The most important feature of documentation is a note by physician in progress note or other appropriate part of patient record stating the indications for transfusion and the expected results. The aim of this study was to evaluate blood request forms as per WHO Guidelines. Materials and Methods The study was conducted in a tertiary care hospital in Uttarakhand after obtaining ethical clearance certificate from the institute. 4236 blood request forms were studied over a period of 12 months. The Blood request forms sent to the blood bank were assessed for adequacy of documentation based on the standard WHO guidelines (4). SPSS version 21 was used for data entry and analysis. Adequacy of documentation are expressed in percentages and depicted in form of tables. Results Out of the total 4236 blood request forms studied, 98.7% (n=4180) had adequate demographic details regarding patient identification details. Diagnosis and Indication of transfusion was mentioned in 70% (n=2967) forms. Investigation details were mentioned only in 68% (n=2883) forms. Only 4 forms had special mention of previous transfusions. Out of these 4236 requisition forms, 0.4% (n=14) forms did not have the sign of the requesting doctor. Conclusion The practice of inadequate documentation has to be changed. Adequate clinical and investigational details should be provided to the transfusion specialist to understand the emergency and to assess appropriateness of transfusions. Clinicians and residents should take a little more time and complete request forms adequately. Top Keywords Transfusion, Documentation. Top |