• 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.

ONLY PHYSICIAN/APN/PA DOCUMENTATION OF THE CLINICAL INDICATION FOR ADMINISTERING RBCs:

• Anesthesia record
• Consultation notes
• Emergency department record
• Operative notes
• Physician orders
• Progress notes