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Documentation and Record Maintenance

You are here : Home/ Blood Bank Zone/ Blood Bank Management/ 9. Documentation & Record Maintenance

9. Documentation & Record Maintenance

Documentation provides the ability to trace prospectively and retrospectively all steps in all procedures, dating from collection of the blood to monitoring techniques, component preparation, laboratory testing, issue and transfusion of blood.

An effective record system helps to judge the performance of the blood transfusion service, traces any donated unit of blood from its source to the final fate and also helps in legal or investigational purposes. Various aspects which need proper documentation are :

. Donor records inlcuding details of donor information, rare donor panels, donor deferraLs and adverse donor reactions.
Record of results and interpretation of all laboratory tests.
Patient’s record (for all patients and specifically important in patients with multiple transfusions, previous transfusion reactions, presence of unexpected antibodies or cross-match problems).
Record of component preparation.
Inventory of blood, blood components, reagents and consummables, etc.
Record of compatibility testing.
Record of discarded blood units.
Record of issue of blood.
Quality control record (which helps in taking corrective actions to improve the performance of any procedure or working of any equipment and reagents).

Record and documents also help to identify possible sources of error in any technique.

The results of manually performed tests should be recorded carefully in a clean and easily understandable way i.e. as the laboratory worksheet. Laboratory worksheets should be preserved as permanent record of the test performed and the readings obtained.

Records of the reagents and kits used for a particular test with their batch no., lot no. and expiry dates should be maintained so that in case of any problem, it is easier to find the source of error.

All records must include the date and signature of the laboratory staff performing the test. Records should be retained for at least 5 years and kept confidential.

Computers are being widely employed in maintaining the records. With the growing demand for improving the efficiency, accuracy and effectiveness it has become imperative to introduce computers in the blood transfusion service.

Computers can help the functions of a blood transfusion service in