JOSE R.

REYES MEMORIAL MEDICAL CENTER

Department of Pathology and Laboratories
BLOOD BANK AND SEROLOGY WORKSHEET

Name: __________________________________________ School: _______________________________

Inclusive Date of Rotation: _________________________

Laboratory Procedure: BLOOD TYPING (FORWARD, REVERSE TUBE METHOD): ABO AND Rh TYPING

Manner of Reporting: Blood Type Rh(D) POSITIVE/NEGATIVE (EX: A Rh(D) POSITIVE)

Lab No. Patients Name Date GRADE OF REACTION (AGGLUTINATION) BLOOD TYPE STAFF ON DUTY/
Performed (INTERPRETATION) CHECKED AND NOTED BY

ANTI-A ANTI-B ANTI-D KNOWN A KNOWN B SECTION HEAD

 JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Pathology and Laboratories
BLOOD BANK AND SEROLOGY WORKSHEET

Name: __________________________________________ School: _______________________________

Inclusive Date of Rotation: _________________________

Laboratory Procedure: COMPATIBILITY TEST/CROSSMATCHING: MAJOR COMPATIBILITY TESTING TUBE METHOD

Manner of Reporting: NO HEMOLYSIS, NO AGGLUTINATION, COMPATIBLE IN 3 PHASES

Lab No. Patients Name Date PATIENTS BLOOD COMPONENT/ SERIAL BLOOD RESULT STAFF ON DUTY/
BLOOD AMOUNT
UNIT NO. BAG NO.
Performed TYPE TYPE INTERPRETATION CHECKED AND NOTED BY
SECTION HEAD
 JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Pathology and Laboratories
BLOOD BANK AND SEROLOGY WORKSHEET

Name: __________________________________________ School: _______________________________

Inclusive Date of Rotation: _________________________

Laboratory Procedure: DONOR SCREENING AND BLEEDING

BLOOD DONATION: DIRECTED, REPLACEMENT AND VOLUNTARY DONATION

SCREENING: INTERVIEW/PE/PRE TESTING TO QUALIFY AS BLOOD DONOR

Date Donors Name AGE/SEX/ REMARKS FOR NUMBER OF HEMATOCRIT/ REMARKS PATHOLOGY RESIDENT STAFF ON DUTY/
Performed WEIGHT INTERVIEW AND PE TIMES OF HEMOGLOBIN INDICATE DECISION ON DUTY
CHECKED AND NOTED BY
DONATION AS TO QUALIFIED OR
DISQUALIFIED SECTION HEAD
 JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Pathology and Laboratories
BLOOD BANK AND SEROLOGY WORKSHEET

Name: __________________________________________ School: _______________________________

Inclusive Date of Rotation: _________________________

Laboratory Procedure: DONOR SCREENING AND BLEEDING

DONOR PHLEBOTOMY/BLEEDING (OF QUALIFIED DONOR)

DATE OF PREVIOUS SERIAL NUMBER/ BLOOD COLLECTION REMARKS PATHOLOGY

DONATION AND BLOOD BAG NUMBER/ TYPE INDICATE AMOUNT INDICATE POST RESIDENT ON DUTY
Date STAFF ON DUTY
Performed
Donors Name AGE/SEX NUMBER OF TIMES EXPIRY DATE COLLECTED DONATION
OF DONATION IF SUCCESSFUL OR REACTION
IF QNS
 JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Pathology and Laboratories
BLOOD BANK AND SEROLOGY WORKSHEET

Name: __________________________________________ School: _______________________________

Inclusive Date of Rotation: _________________________
Laboratory Procedure: TRANSFUSION TRANSMITTED TESTS AND SEXUALLY TRANSMITTED TESTS
HBsAg, HIV TYPE I AND TYPE II, HEPATITIS C AND SYPHILIS

HBsAg (Hepatitis B surface Antigen)

Reagent: _____________________________________
Lot #: _______________________________________
Expiry Date: __________________________________
Control: Negative Control: _______________________
Positive Control: _______________________

Lab No.
Date Patients Name Serial no./BB # METHOD PRINCIPLE COV OD/ABSORBANCE INTERPRETATION STAFF ON DUTY
Performed CHECKED AND
NOTED BY
SECTION HEAD
 JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Pathology and Laboratories
BLOOD BANK AND SEROLOGY WORKSHEET

Name: __________________________________________ School: _______________________________

Inclusive Date of Rotation: _________________________
Laboratory Procedure: TRANSFUSION TRANSMITTED TESTS AND SEXUALLY TRANSMITTED TESTS
HBsAg, HIV TYPE I AND TYPE II, HEPATITIS C AND SYPHILIS

HIV (HUMAN IMMUNODEFICIENCY VIRUS)

Reagent: _____________________________________
Lot #: _______________________________________
Expiry Date: __________________________________
Control: Negative Control: _______________________
Positive Control: _______________________

Lab No.
Date Patients Name Serial no./BB # METHOD PRINCIPLE COV OD/ABSORBANCE INTERPRETATION STAFF ON DUTY
Performed CHECKED AND
NOTED BY
SECTION HEAD
 JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Pathology and Laboratories
BLOOD BANK AND SEROLOGY WORKSHEET

Name: __________________________________________ School: _______________________________

Inclusive Date of Rotation: _________________________
Laboratory Procedure: TRANSFUSION TRANSMITTED TESTS AND SEXUALLY TRANSMITTED TESTS
HBsAg, HIV TYPE I AND TYPE II, HEPATITIS C AND SYPHILIS

HCV (Hepatitis C VIRUS)

Reagent: _____________________________________
Lot #: _______________________________________
Expiry Date: __________________________________
Control: Negative Control: _______________________
Positive Control: _______________________

Lab No.
Date Patients Name Serial no./BB # METHOD PRINCIPLE COV OD/ABSORBANCE INTERPRETATION STAFF ON DUTY
Performed CHECKED AND
NOTED BY
SECTION HEAD
 JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Pathology and Laboratories
BLOOD BANK AND SEROLOGY WORKSHEET

Name: __________________________________________ School: _______________________________

Inclusive Date of Rotation: _________________________
Laboratory Procedure: TRANSFUSION TRANSMITTED TESTS AND SEXUALLY TRANSMITTED TESTS
HBsAg, HIV TYPE I AND TYPE II, HEPATITIS C AND SYPHILIS

SYPHILIS: RAPID PLASMA REAGIN (RPR)

Reagent: _____________________________________
Lot #: _______________________________________
Expiry Date: __________________________________
Control: Negative Control: _______________________
Positive Control: _______________________

Lab No.
Date Patients Name Serial no./BB # METHOD PRINCIPLE COV OD/ABSORBANCE INTERPRETATION STAFF ON DUTY
Performed CHECKED AND
NOTED BY
SECTION HEAD
 JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Pathology and Laboratories
BLOOD BANK AND SEROLOGY WORKSHEET

Name: __________________________________________ School: _______________________________

Inclusive Date of Rotation: _________________________

Laboratory Procedure: CRP/ASO/RF TEST (QUALITATIVE AND/OR QUANTITATIVE)

C-REACTIVE PROTEIN (CRP)

Lab No. Patients Name Date PRINCIPLE RESULT (INTERPRETATION AND STAFF ON DUTY/
Performed MANNER OF REPORTING, CHECKED AND NOTED BY
SECTION HEAD
INDICATE METHOD USED)

RHEUMATOID FACTOR (RF)

Lab No. Patients Name Date PRINCIPLE RESULT (INTERPRETATION AND STAFF ON DUTY/
Performed MANNER OF REPORTING, CHECKED AND NOTED BY
SECTION HEAD
INDICATE METHOD USED)