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C
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LYX
OMPONENT
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PPENDIX
Sample 2RBC
Procedure Data Sheet
Site: __________________ Fixed/Mobile Instrument Serial #: __________ Unit # __________
Site: __________________ Fixed/Mobile Instrument Serial #: __________ Unit # __________
Site: __________________ Fixed/Mobile Instrument Serial #: __________ Unit # __________
Donor's Name: _____________________________
Donor's Name: _____________________________
DOB: __________ Wt: ______ Ht: ______
DOB: __________ Wt: ______ Ht: ______
Arm Used: R / L Pre Hct/Hgb: Vital Signs: Temp
Kit Code __________ Kit Lot # ________
Saline Code ________ Saline Lot # ______________
Saline Code ________ Saline Lot # ______________
RBC Product Volume
Red Cell Preservation
Solution Volume
Anticoagulant
Volume
Proc Start Time ____:____ Proc End Time ____:____
Proc Start Time ____:____ Proc End Time ____:____
Proc Start Time ____:____ Proc End Time ____:____
Volume
Time
Collected (mL)
Abs RBC
Volume
_________mL
Saline Used
Filtration Data:
Filtration Data:
Filtration Time ____:____ (min:sec) Percent Post Leukoreduction Recovery____
Filtration Time ____:____ (min:sec)
Comm ents:___________________________________________________________________________________________
ents:___________________________________________________________________________________________
ents:___________________________________________________________________________________________
Operator's Signature ________________________________ Reviewer's Signature_________________________________
Operator's Signature ________________________________ Reviewer's Signature_________________________________
Operator's Signature ________________________________ Reviewer's Signature_________________________________
A-12
S
O
OLLECTION
YSTEM
YSTEM
A
2RBC-LR Procedure
LYX
LYX
A. DONOR INFORMATION/VITAL
A. DONOR INFORMATION/VITAL SIGNS
Vital Signs: Temp
B. DISPOSABLE
B. DISPOSABLE INFORMATION
________ _______
C. PRODUCT INFORMATION
C. PRODUCT INFORMATION
RED CELL PRODUCTS
RED CELL PRODUCTS
Product A
Product A
_______
_______
_______
_______
_______
_______
D. PROCEDURE INFORMATION
D. PROCEDURE INFORMATION
(hrs:min)
Flow Rate
Cycle
Cycle
mL/Min
Draw/Return
Draw/Return
D
D
D
D
D
Total RBC
Volume
Volume
'
M
PERATOR
S
ANUAL
WORKSHEET
SS# ____________________
Sex: M /F
ABO/Rh: __________
B/P
Exp. Date: _______
Exp. Date: _______
Product B
Product B
_______
_______
_______
Total Proc Time
Total Proc Time
Total Proc Time
(hrs:min)
Comments/Alarms
R
R
R
R
R
_________mL
_________mL
Anticoagulant Used
Leukoreduction Recovery____ %
Date: __________________
Date: __________________
Pulse
__________ min.
__________ min.
__________ min.
VP
Check
Check
S
U
U
S
U
U
S
U
U
S
U
U
S
U
U
Total Volume
Processed
_________mL
_________mL
07-19-01-518 –
– January 2009
Staff
Initials
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