Fenwal 4R5707 Operator's Manual page 441

Sample RBC/Plasma
Procedure Data Sheet
Site: _________________ Fixed/Mobile Instrument Serial #: __________ Unit # ___________ Site: _________________ Fixed/Mobile Instrument Serial #: __________ Unit # ___________ Site: _________________ Fixed/Mobile Instrument Serial #: __________ Unit # ___________
Donor's Name: _____________________________ SS# ____________________ Donor's Name: _____________________________
DOB: __________ Wt: ______ Ht: ______ DOB: __________ Wt: ______ Ht: ______
Arm Used: R / L Pre Hct/Hgb:
Kit Code ______________
PLASMA PRODUCT (or) (or)
Plasma
Product
Volume _______
Anticoagulant
Volume _______
Proc Start Time ____:____ Proc End Time ____:____ ____:____ Proc End Time ____:____
(hrs:min)
Volume
Time Collected (mL) Collected (mL)
Abs RBC
Volume Volume _________mL Volume _________mL Volume
Saline Used
Filtration Data
Comments:_____________________________________________________________________ Comments:_____________________________________________________________________ _______________ Comments:_____________________________________________________________________
____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ _________
Operator's Signature ______________________ ______________________ ______ _ Reviewer's Signature____________
07-19-01-518 – January 2009
A C
LYX OMPONENT
A
RBC/Plasma Procedure
LYX
WORKSHEET
A. DONOR INFORMATION/VITAL SIGNS A. DONOR INFORMATION/VITAL SIGNS
Sex: M /F
Vital Signs: Temp
B. DISPOSABLE INFORMATION
Kit Lot #_________________ Kit Lot #_________________
C. PRODUCT INFORMATION
PLASMA PRODUCTS PLASMA PRODUCTS
Total Total
Plasma Plasma
Volume Volume ______ ______
Product A Product A
Plasma Plasma
Volume Volume ______ ______
Anticoagulant Anticoagulant
Volume Volume ______ ______
Product B Product B
Plasma Plasma
Volume Volume ______ ______
Anticoagulant Anticoagulant
Volume Volume ______
D. PROCEDURE INFORMATION
hrs:min)
Flow Rate Flow Rate Cycle
mL/min mL/min Draw/Return Draw/Return
D R
D R
D R
D R
D R
Total RBC Total RBC
______mL ______mL
Filtration Time ____:____ (min:sec) Filtration Time ____:____ (min:sec) Percent Post Leukoreduction Recovery ______
_ Reviewer's Signature____________________ _________
C S
OLLECTION YSTEM YSTEM
Date: _________________ Date: _________________
ABO/Rh: __________
B/P Pulse
Exp. Date: _______________ Exp. Date: _______________
RED CELL PRODUCT RED CELL PRODUCT
RBC Product
Volume Volume
RBC Preservation
Solution Volume Solution Volume
Anticoagulant
Volume Volume
Total Proc. Time __________ min. __________ min.
Comments/Alarms
Total Volume
Processed Processed _________mL _________mL
Anticoagulant Used
Post Leukoreduction Recovery ______ %
O ' M
PERATOR S ANUAL
A
PPENDIX
_________ _________
_________ _________
_________ _________
VP Staff
Check Initials
S U
S U
S U
S U
S U
A-13