RUMAH SAKIT

MAYANG MEDICAL CENTRE

Jl. Ir. H, Juanda No.56 Simpang III Sipin. Mayang ManguraiKec. Kota Baru. Jambi 36126
. Telp. 0741-671222, 7078688. Fax. 0741-61468
Email : rumkitmayang @gmail.com

NO MR :

Nama : ............................................... Laki-laki / Perempuan

Umur : ............Th /Bln/Hr
Ruangan : .............................................. Tanggal : ..............................................

DOKUMEN MEDIK TRANSFUSI

Berat Badan : ........ Kg Reaksi Silang :

Diagnose : ............................ Mayor : ............................
Gol. Darah : ............................. Minor : ............................
UNIT KE 1 2 3 4 5 6
Komponen
(a – d)
a. Whole Blood (WB) b. Packed Red Cell (PRC) c. Thrombocyte Concentrate (TC)
d. Fresh Frozen Plasma (FFP)
No. Seri :
Jam Mulai :
Jam Selesai :
Waktu Transfusi
(a – d)
a. Pre –OP b. Durante – OP c. Post –OP d. Non-OP
Jenis Reaksi Transfusi (  ):
Demam
Alergi
Hemolitik
Sepsis
Overload
Lainnya

Tekanan Darah Pra-Transfusi : .................................. selesai transfusi : ..................................................

Suhu Pra-Transfusi : .................................. selesai transfusi : ..................................................
HB Pra- Transfusi : ................................. selesai transfusi : ..................................................
Indikasi Transfusi :
Ane Perdarahan Akut Gangguan Hemostasis
Lainnya. ...............................................................................................................................................

OBAT PRA-TRANSFUSI : Antipiretika Diuretika Antihistamin Steroid

Jambi, .........................20.....
Dokter

...............................................

PERTIMBANGKAN : 1. Indikasi Transfusi Kuat Jika HB < 8 g/dl

2. Akhir transfusi cukup sampai 10 Hb g/dl