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RUMAH SAKIT IBU DAN ANAK MUTIARA BUNDA

JL.Dr. Cipto Mangunkusumo No. 3 ( Jl. H. Mencong )


Ciledug-Tangerang
Telp. 021 7301365-73454951

LAPORAN KEJADIAN REAKSI TRANSFUSI

Nama : ........................................................................................................
Alamat : ........................................................................................................
No.Register : ........................................................................................................
Jenis Komponen Darah : ........................................................................................................
Jenis Reaksi : ........................................................................................................
Kronologis Kejadian : ........................................................................................................

Tindak Lanjut

Tangerang,...........20....
Yang membuat laporan

Catatan : Mohon labu yang menimbulkan reaksi transfusi dikembalikan ke Bank Darah FORM-LAB-14-00

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