Home » Clinical Indication for RBCs
Print this page

Release Notes:
Data Element
Version 2010B

Data Element Name: Clinical Indication for RBCs
Collected For: BM-02,
Definition:Documentation by the physician/advance practice nurse/physician assistant (physician/APN/PA) of the clinical indication for the red blood cell (RBCs) transfusion event.
Suggested Data Collection Question:What was the clinical indication documented by the physician/APN/PA for the RBC transfusion event?
Occurs: 1 - 3
Allowable Values:

Select the indication for the RBC transfusion event:

1    Bleeding

2    No bleeding, but evidence of inadequate oxygen delivery

3    Other

4    No documentation of clinical indication for the RBC transfusion

Notes for Abstraction:
  • The clinical indication for the transfusion must be documented within 24 hours after the start of the transfusion event.
  • Select the first three RBC transfusion events after hospital arrival for abstraction.
  • Select "1" if there is documentation of ‘hemorrhagic shock' or 'evidence of acute hemorrhage and hemodynamic instability or inadequate oxygen delivery' or a 'massive transfusion protocol' was used.
  • Select “2” if there is documentation that the patient was transfused for a physiologic indication with evidence of inadequate oxygen delivery. For example: there is documentation such as: shortness of breath at rest (with no other cause such as underlying pulmonary dysfunction), syncope or fainting (once hypovolemia is ruled out), tachycardia or hypotension (that volume replacement failed to correct), unresponsive or signs of organ ischemia (somulence, or ST segment changes).
  • Select "3" if there is an indication for RBCs but the documentation is unclear as to whether the blood was administered due to a physiologic indication that caused a oxygen carrying deficit.
Suggested Data Sources:


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

Clinical Indication for RBCs
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)