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