1 Soarian Update Transfusion Record 4/19/11

2 Document transfusion of blood in Soarian Patient has transfusion of blood product ordered. Blood product arrives to the unit. Transfusionist arranges with witness to check the blood order, product label check and matches patient name, MR# and wristband check to blood product label. This process is to be done at bedside.

3 Transfusion Record is on the filtered list At the patient bedside…Transfusionist nurse logs onto Soarian and selects the patient charting screen. Select assessments and pick Transfusion Record from the Filtered list. Bedside patient Blood ID Check is completed. This is mandatory. All dropdown values are required. Verification date is the time that you perform this step. Transfusionist enters name and title. Witness reads off the blood product ID# and the expiration date. Transfusionist enters date into this field.

4 Witness verification The transfusionist statuses the assessment as In Progress and logs out of Soarian. The witness logs into Soarian and opens the patient record. Selects Charting. Click on assessments and finds the In Progress Transfusion Record under Scheduled/Incomplete Assessments. Pre and 5 minute VS are not available to the transfusionist until this step in complete.

5 Witness verification continued… The witness enters name and title in Witness/MD/RN/LPN. By completing this step, witness signature is evidence of the verification step.

6 Witness verification confirmed and Transfusionist continues with the documentation process The witness then statuses the form as In Progress and electronically signs the form. Witness now logs out of Soarian. Transfusionist now logs back into Soarian and documents Pre- Transfusion VS. Save as In Progress. Date/Time started are charted. Transfusionist stays at the bedside and 5-minute VS are then recorded. Save the asmt as In Progress. Transfusionist may now log out of Soarian.

7 Completion of the Transfusion Upon completion of the transfusion, assessment is documented. Transfusionist nurse logs into Soarian and once again opens Charting screen. The Transfusion Record is found under the Scheduled/Incomplete Assessments. Post- Transfusion VS, Date/Time, Transfusionist signature and volume infused are entered. Blood warmer temp is available for charting.

8 Transfusion Reaction When Transfusion Reaction is checked an informational message appears for accountability. Directions must be followed on the back of the paper blood transfusion record that you received from the blood bank.

9 Transfusion Reaction continued… If and when Transfusion Reaction is checked and the asmt is signed as Complete, a STAT Transfusion Reaction Evaluation is auto ordered to the lab. The phlebotomist will come to the unit to draw the specimen. If the patient has a line, the phlebotomist will change the draw to a nurse draw. This specimen must be sent back to the lab with the patient paper Transfusion Record and the remaining blood product bag. Because the Transfusion documentation is now in Soarian, a line can be drawn through that portion and “In Soarian” with date and initials can be annotated. Other areas in the hospital will still be using this paper documentation. Also when the Transfusion Reaction is checked and the finished asmt is signed as Complete, the Transfusion Record Assessment is auto printed to the lab. Transfusion reactions need to be selected from the list Comments are available.