NORTH BRISTOL NHS TRUST

DEPARTMENT OF BLOOD TRANSFUSION

NHS or Hospital Number All shaded areas to be completed.
For Laboratory Use sample barcode
Surname Name……………………………… Signature ……………………
Job role.……..………………………Contact No. ...............................

Forename Date and Time .............. / .............. / ............... ........... : ...........

Sample Collection
I confirm that I have taken the blood sample for this request in
D.O.B. Sex (M/F) Patient Type accordance with the NBT Policy, (Summary overleaf) and labelled
D D MM Y Y Y Y NHS PP in the presence of the patient. I have confirmed the patient’s
identity both verbally and with the wristband where available.
Consultant / GP Location
Name .................................... Signature .....................................
Date and Time .............. / .............. / .............. ........... : ...........

Clinical Details / Procedure: Current Hb/Plt…..… Known antibodies

If blank indicates unknown
Target Hb/Plt…..….
Previous reactions Y/N Details:
For elective surgical patients check MSBOS for blood requirements If blank indicates unknown

Tests Components required Tick Quantity Indication Special Required for

below Required Code (see over) requirements
Group and Save Date ___/___/___
Red Blood Cells (please phone laboratory
DAT Consider one unit and recheck Hb to alert if new requirement)
Phenotyping For Exchange phone the lab If blank indicates unknown
Time ___:___
i.e. Starting monoclonal FFP
therapy (e.g. CD38 CD47) Irradiated Blood fridge location
Fetal Leak: Platelets CMV for RBC
Other i.e . L0, 1, 2, 3, 5, CDS,
Weeks gestation Cryoprecipitate external location

EDD ___/___/___ Reason

Other (HAS, Anti-D) If not provided blood
will be held in the
or Postnatal laboratory

Southmead Hospital, Telephone Bristol 0117 4148350

 Failure to complete the request form fully may delay processing of request or even result in the rejection of the sample and request

Code Adult Indication RBC Code Adult Indication PLATELETS Irradiated

R1 Acute bleeding Prophylactic platelet transfusion: 7 days prior to bone marrow or stem cell harvest
R2 Acute anaemia 9
P1 <10 x 10 /L reversible bone marrow Following bone marrow or stem cell transplantation
Stable patient 70g/L failure Following treatment with Fludarabine, Chemo-oxy-adenosine
Hb Target = 70-90g/L P2 10-20 x 109/L sepsis/haemostatic 2 (CdA), Deoxycoformycin, Clorfarabine, Pentostatin,
R3 Acute anaemia abnormality Bendamustine, Alemtuzumab, other Purine analogues and
Cardio vascular disease 80g/L Prior to invasive procedure or related drugs.
Hb Target = 80-100g/L surgery if: Congenital immunodeficiency
R4 Chronic Transfusion P3a <20 x 109/L central venous line Intra uterine transfusion (IUT) / exchange transfusion
Dependant Anaemia 80g/L P3b <40 x 109/L pre lumbar Neonates who have had a IUT
Hb Target =To prevent symptoms puncture/spinal anaesthesia Hodgkins disease
R5 Radiotherapy 110g/L P3c <50 x 109/L pre liver biopsy/major Following anti-thymocyte globulin (ATG)
BOS Blood requested in line with the surgery If in doubt speak to a haematologist
NBT MSBOS (provide details) P3d <80 x 109/L epidural anaesthesia CMV
Code Indication FFP P3e <100 x 109/L pre critical site surgery Neonates up to 28 days past their due date
F1 Major haemorrhage e.g. CNS Pregnant women having an elective transfusion
F2 PT ratio/INR >1.5 with bleeding Therapeutic use to treat bleeding
F3 PT ratio/INR >1.5 and pre- P4a Major haemorrhage Collection of Blood Samples
procedure P4b Empirically in a Major Haemorrhage  Patient ID must be checked verbally (where possible) on
F4 Liver disease with PT ratio/INR >2 Pack / Protocol
wristband (for inpatients) and with request form prior to
and pre-procedure P4c Critical site bleeding e.g. CNS Plt
<100 x 109/L taking blood sample.
F5 TTP/plasma exchange
F6 Replacement of single coagulation P4d Clinically significant bleeding Plt <30 x  Samples must be labelled immediately at the bedside using
factor 109/L patient ID from the wristband for all inpatients
Code Indication CRYO Specific clinical conditions  Sample tubes must not be pre-labelled
C1 Clinically significant bleeding and P5a DIC pre procedure or if bleeding  Patient details must be identical on the sample and form.
fibrinogen <1.5g/L (<2g/L in P5b Primary immune thrombocytopenia  Tubes must be labelled with the following patient ID:
obstetric bleeding) (emergency pre-procedure/severe o Unique number
C2 Fibrinogen <1g/L and pre- bleeding) o Surname
procedure P6 o First name
C3 Bleeding associated with Platelet dysfunction
o Date of birth
thrombolytic therapy P6a Consider if critical bleeding on anti- In the absence of secure electronic bedside phlebotomy
C4 Inherited hypofibrinogenaemia platelet agent  Demographic labels must not be used on the sample
when fibrinogen concentrate not P6b Inherited platelet disorders directed by
 The date and time must be included on sample and form
available a haemostasis specialist
 Sample and form declaration must be signed by the person
taking the sample