Sync template from atomicqms-style deployment
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Forms/Testing-Logs/FRM-BB-001-Compatibility-Testing-Log.md
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Forms/Testing-Logs/FRM-BB-001-Compatibility-Testing-Log.md
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# Compatibility Testing Log
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| Form ID | FRM-BB-001 | Revision | 1.0 |
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|---------|-------------|----------|-----|
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---
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## Patient Information
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| Field | Entry |
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|-------|-------|
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| Patient Name | |
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| MRN | |
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| Date of Birth | |
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| Sex | ☐ Male ☐ Female |
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| Location/Unit | |
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| Ordering Physician | |
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| Date of Request | |
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| Time of Request | |
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---
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## Specimen Information
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| Field | Entry |
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|-------|-------|
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| Date Collected | |
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| Time Collected | |
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| Collected By | |
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| Phlebotomist ID | |
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| Tube Type | ☐ EDTA ☐ Clot ☐ Both |
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| Specimen Acceptable? | ☐ Yes ☐ No (reason: _______) |
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| Previous Records Available? | ☐ Yes ☐ No ☐ N/A |
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---
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## ABO/Rh Typing
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### Current Sample
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| Test | Result | Interpretation |
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|------|--------|----------------|
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| Anti-A | ☐ Pos ☐ Neg | |
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| Anti-B | ☐ Pos ☐ Neg | |
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| Anti-D | ☐ Pos ☐ Neg | |
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| A1 Cells | ☐ Pos ☐ Neg | |
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| B Cells | ☐ Pos ☐ Neg | |
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**ABO Type:** ☐ A ☐ B ☐ AB ☐ O
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**Rh Type:** ☐ Positive ☐ Negative
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**Weak D Testing (if applicable):**
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☐ Not performed ☐ Positive ☐ Negative
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### Historical Results (if available)
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| Date | ABO | Rh | Source |
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|------|-----|----|--------|
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| | | | |
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| | | | |
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**Results Consistent?** ☐ Yes ☐ No (see discrepancy resolution)
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---
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## Antibody Screening
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| Field | Entry |
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|-------|-------|
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| Method | ☐ Tube ☐ Gel ☐ Solid Phase |
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| Enhancement | ☐ LISS ☐ PEG ☐ None |
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| Screen Cell Lot # | |
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| Expiration Date | |
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### Screen Cell Results
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| Cell | Immediate Spin | 37°C | AHG | CC |
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|------|----------------|------|-----|-----|
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| I | | | | |
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| II | | | | |
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| III | | | | |
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**Antibody Screen Result:** ☐ Negative ☐ Positive
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**If Positive, Antibody Identified:**
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---
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## Antibody Identification (if screening positive)
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| Field | Entry |
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|-------|-------|
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| Panel Lot # | |
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| Method | |
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| Antibody(ies) Identified | |
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| Clinical Significance | ☐ Yes ☐ No |
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| Phenotyped Units Required? | ☐ Yes ☐ No |
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| Phenotype Requirements | |
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| Panel Cell | Results | Antigen Correlation |
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|------------|---------|---------------------|
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| 1 | | |
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| 2 | | |
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| 3 | | |
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| 4 | | |
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| 5 | | |
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| 6 | | |
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| 7 | | |
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| 8 | | |
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| 9 | | |
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| 10 | | |
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| 11 | | |
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---
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## Crossmatch
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### Unit 1
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| Field | Entry |
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|-------|-------|
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| Unit Number | |
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| ABO/Rh | |
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| Expiration Date | |
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| Antigen Typed? | ☐ Yes: _______ ☐ No ☐ N/A |
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| Phase | Result | Interpretation |
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|-------|--------|----------------|
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| Immediate Spin | ☐ Compatible ☐ Incompatible | |
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| 37°C | ☐ Compatible ☐ Incompatible | |
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| AHG | ☐ Compatible ☐ Incompatible | |
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| Coombs Control | ☐ Valid ☐ Invalid | |
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**Final Result:** ☐ Compatible ☐ Incompatible
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### Unit 2
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| Field | Entry |
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|-------|-------|
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| Unit Number | |
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| ABO/Rh | |
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| Expiration Date | |
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| Antigen Typed? | ☐ Yes: _______ ☐ No ☐ N/A |
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| Phase | Result | Interpretation |
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|-------|--------|----------------|
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| Immediate Spin | ☐ Compatible ☐ Incompatible | |
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| 37°C | ☐ Compatible ☐ Incompatible | |
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| AHG | ☐ Compatible ☐ Incompatible | |
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| Coombs Control | ☐ Valid ☐ Invalid | |
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**Final Result:** ☐ Compatible ☐ Incompatible
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### Unit 3
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| Field | Entry |
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|-------|-------|
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| Unit Number | |
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| ABO/Rh | |
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| Expiration Date | |
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| Antigen Typed? | ☐ Yes: _______ ☐ No ☐ N/A |
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| Phase | Result | Interpretation |
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|-------|--------|----------------|
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| Immediate Spin | ☐ Compatible ☐ Incompatible | |
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| 37°C | ☐ Compatible ☐ Incompatible | |
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| AHG | ☐ Compatible ☐ Incompatible | |
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| Coombs Control | ☐ Valid ☐ Invalid | |
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**Final Result:** ☐ Compatible ☐ Incompatible
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---
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## Electronic Crossmatch (if applicable)
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| Field | Entry |
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|-------|-------|
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| Two ABO/Rh on file? | ☐ Yes ☐ No |
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| Results consistent? | ☐ Yes ☐ No |
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| Antibody screen negative? | ☐ Yes ☐ No |
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| Computer system validated? | ☐ Yes |
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---
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## Special Requirements
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| Requirement | Ordered? | Provided? |
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|-------------|----------|-----------|
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| CMV Negative | ☐ | ☐ |
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| Irradiated | ☐ | ☐ |
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| Leukoreduced | ☐ | ☐ |
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| Washed | ☐ | ☐ |
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| Volume Reduced | ☐ | ☐ |
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| HbS Negative | ☐ | ☐ |
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| Antigen Negative: _______ | ☐ | ☐ |
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---
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## Results Summary
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| Field | Entry |
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|-------|-------|
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| ABO/Rh | |
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| Antibody Screen | ☐ Negative ☐ Positive |
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| Antibodies Identified | |
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| Units Crossmatched | |
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| Units Compatible | |
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| Units Available for Issue | |
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---
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## Verification
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### Performed By
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| Field | Entry |
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|-------|-------|
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| Technologist Name | |
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| Tech ID | |
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| Date | |
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| Time | |
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| Signature | |
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### Reviewed By (if required)
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| Field | Entry |
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|-------|-------|
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| Reviewer Name | |
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| Date | |
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| Signature | |
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---
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## Discrepancy Resolution (if applicable)
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| Field | Entry |
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|-------|-------|
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| Type of Discrepancy | |
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| Investigation Performed | |
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| Resolution | |
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| Resolved By | |
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| Date | |
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| Supervisor Review | |
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---
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|
||||
*Form FRM-BB-001 Rev 1.0 - Compatibility Testing Log*
|
||||
Reference in New Lab Ticket
Block a user