Apheresis Procedure Record

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					Apheresis Record
Date: _____________Procedure:______________________Collection NO:_____________________ Doctor:_________________________Beeper:________________ Apheresis Nurse:__________________________ Location of Procedure Ambulatory Care Centre Intensive Care Unit PRE-PROCEDURE CHECKS (Please √, sign and date to acknowledge) Consent Completed Completed Prescription for HPC collection (CT-F-089) Infectious Disease Blood Crossmatched Markers (where machine blood prime
(valid 30 days) required)

Room Number

Donor Blood Group
(performed in last 7 days) Sign and date to confirm

Donor assessed and orders completed (MR690/A) by Medical Officer
Sign and date to confirm

DONOR DETAILS Height (cm): Weight (kg):
Sign and date to confirm

Total Blood Volume (TBV): Total Plasma Volume(TPV):
Sign and date to confirm

VASCULAR ACCESS PERIPHERAL Access Vein Return Vein
Sign and date to confirm

VASCATH Access Return
Sign and date to confirm

PATHOLOGY RESULTS (complete from CLARA as applicable & if indicated)
PARAMETER Hb (g/L) HCT PLTS WCC ( x10 /L) Neut. Lymph. Mono. MNC (Lymph.+Mono.) CD34+x10 /mL Ca (ionised) mmol/L “other” Sign and date AP-F-004 Version: 002 Date Effective: 10.03.09 Page 1 of 4 Prepared by: Nancy Messino Reviewed by: David Sutton Authorised by: Brendan Cusack Printed Version is a Controlled Document ONLY if stripe on Margin is RED
2+ 3 9

PRE

MIDWAY

POST

Apheresis Record
PROCEDURE LOG Machine ID Procedure Anticoagulant Priming Solution ACD-A / Heparin 0.9% N/Saline / Packed Cells

Set-up / Consumables Record Set-up Consumable Serial No/Expiry Kit Burette Blood Filter Blood Warmer 0.9% N/Saline 1000ml 0.9% N/Saline 500ml ACD-A 500ml “Other” Machine Set-Up Check Machine Test Set up time Prime Time
Sign and date to confirm

Access: Fistula Needle IV Cannula 0.9% N/Saline 10ml Syringe 3 Way Tap IV Bung “Other”
Sign and date to confirm

Serial No/Expiry

Procedure Data Time Inlet (ml) Plasma (ml) Collect/ Replace (ml) AC Ratio AC infuse rate Comments

POST PROCEDURE Collection Data Start Time Finish Time Total Process Volume(a) Total ACD-A Volume (b)
Total Blood Volume (a-b)

Parameter

Collection Summary ACD-A added to Bag Total Bag Volume

Parameter

Sealer Volume
Sign and date to confirm AP-F-004 Version: 002 Date Effective: 10.03.09

Machine Cleaned
Sign and date to confirm Page 2 of 4 Prepared by: Nancy Messino Reviewed by: David Sutton Authorised by: Brendan Cusack Printed Version is a Controlled Document ONLY if stripe on Margin is RED

Apheresis Record
OBSERVATIONS
HRS

TIME
MINS

STAFF INITIAL

TEMP
220 200 200 180 160 140 120 100 80 60 40 20

180 160 140 HR / BP / RR 120 100 80 60 40 20

COMMENTS

PROGRESS NOTES

AP-F-004 Version: 002 Date Effective: 10.03.09

Page 3 of 4

Prepared by: Nancy Messino Reviewed by: David Sutton Authorised by: Brendan Cusack

Printed Version is a Controlled Document ONLY if stripe on Margin is RED

Apheresis Record
FINAL PRODUCT LABELLING AND HANDOVER PRODUCT LABELLING Labelled by: (Apheresis Nurse to Sign) Checked by: (Scientist /Nurse to Sign) Destination (Laboratory) HANDOVER CUSTODY OF CARE HPC-A Product Unique Identifier
(Scientist to attach Medipath Number)

Date & Time Collector Notified:

Product Labelled and collected by: (Scientist to Sign) Check and Hand over by: (Apheresis Nurse to Sign) Date and Time
(HPC-A Product leaves Collection Facility)

NOTE: This original completed Apheresis Procedure Form MUST be filed in the Donor’s Medical History. A copy of this form is to accompany the labelled HPC-A Product to the Processing Laboratory.

AP-F-004 Version: 002 Date Effective: 10.03.09

Page 4 of 4

Prepared by: Nancy Messino Reviewed by: David Sutton Authorised by: Brendan Cusack

Printed Version is a Controlled Document ONLY if stripe on Margin is RED


				
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