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Release Notes:
Data Element
Version 2010A1

Data Element Name: Transfusion Order
Collected For: BM-05,
Definition:An order to transfuse was written by the physician/advance practice nurse/physician assistant (physician/APN/PA) prior to the initiation of the transfusion.
Suggested Data Collection Question:Was there documentation of an order to transfuse prior to the transfusion?
Format:
Length:1
Type:Numeric
Occurs:1 - 9
Allowable Values:

1    There was documentation of an order to transfused prior to transfusion.

2    There was no documentation of an order to transfuse prior to transfusion or unable to determine from medical record documentation.

Notes for Abstraction:
  • A verbal or telephone order that was written prior to the transfusion is acceptable.
  • The Transfusion Order must be associated with the blood product event ID that was selected for abstraction. For example, if a patient received RBCs, the abstractor will select the first order for RBCs "Transfuse one unit of RBCs" as RBC Event ID #1.
  • Select N if there is only an order to T & C or T & S.
  • Note: Transfusion Order is written per event and may apply to more than one unit (bag) or dose. For example: An order written to "Transfuse two doses of platelets" would apply to both units that were administered.
Suggested Data Sources:

ONLY PHYSICIAN/APN/PA DOCUMENTATION OF THE ORDER TO TRANSFUSE:

  • Anesthesia record
  • Consultation notes
  • Emergency department record
  • Operative notes
  • Physician orders
  • Progress notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Transfusion Order
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)