• Documentation that addresses the risks of transfusion must include the specific risks of the blood product (s) that was administered to select “Yes”.
• Use only documentation provided in the medical record itself. Do not review and use outside materials in abstraction. Do not make assumptions about what content may have been covered in the discussion with the patient/caregiver.
• If the patient refused information about transfusion risks, select “Yes.”
• The caregiver is defined as the patient’s family or any other person (e.g., guardian) who will be responsible for care of the patient.

ONLY PHYSICIAN/APN/PA DOCUMENTATION:

• Admission forms
• Consent form
• Consultation notes
• Emergency department record
• History and physical
• Progress notes