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A
C
C
LYX
OMPONENT
A
PPENDIX
Sample 2RBC-NLR
Procedure Data Sheet
Site: __________________ Fixed/Mobile Instrument Serial #:
Site: __________________ Fixed/Mobile Instrument Serial #: __________ Unit # __________
Donor's Name: _____________________________
Donor's Name: _____________________________
DOB: __________ Wt: ______ Ht: ______
DOB: __________ Wt: ______ Ht: ______
Arm Used: R / L
Kit Code __________ Kit Lot #________ _
Kit Code __________ Kit 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 ____:____
(hrs:min)
Volume
Time
Collected (mL)
Abs RBC
Volume
Volume
_________mL Volume
_________mL Volume
Saline Used
Comments:____________________________________________________________________________________
Comments:____________________________________________________________________________________
Comments:____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________ _________
Operator's Signature _____________________________ Reviewer's Signature_____________________________
Signature _____________________________ Reviewer's Signature_____________________________
Signature _____________________________ Reviewer's Signature_____________________________
A-14
S
O
OLLECTION
YSTEM
YSTEM
A
2RBC-NLR Procedure
LYX
LYX
A. DONOR INFORMATION/VITAL SIGNS
A. DONOR INFORMATION/VITAL SIGNS
Pre Hct/Hgb:
B. DISPOSABLE INFORMATION
B. DISPOSABLE INFORMATION
C. PRODUCT INFORMATION
C. PRODUCT INFORMATION
RED CELL PRODUCTS
RED CELL PRODUCTS
Product A
Product A
_______
_______
_______
_______
_______
_______
D. PROCEDURE INFORMATION
PROCEDURE INFORMATION
Flow Rate
mL/Min
Draw/Return
D
D
D
D
D
Total RBC
Total RBC
'
M
PERATOR
S
ANUAL
WORKSHEET
__________ Unit # __________
SS# ____________________
SS# ____________________
Sex: M /F
Vital Signs: Temp
Exp. Date: __ ____
Product B
Product B
_______
_______
_______
_______
Total Proc Time
Total Proc Time
Total Proc Time
(hrs:min)
Cycle
Comments/Alarms
R
R
R
R
R
_________mL
_________mL
Anticoagulant Used
Date: __________________
Date: __________________
ABO/Rh: __________
ABO/Rh: __________
B/P
Pulse
Pulse
__________ min.
__________ min.
__________ min.
VP
Check
Check
S
U
S
U
S
U
S
U
S
U
Total Volume
Processed
_________mL
07-19-01-518 –
– January 2009
Staff
Initials
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