Enterprise Management Blood System

DONATION IDENTIFICATION
NUMBER

BLOOD DONATION RECORD
SECTION I -

Womack Army Medical Center - Blood Donor Ctr

1. DONATION FACILITY

BRG-DRV0000647

SECTION II

2. DON/PROC

3. TODAY'S DATE

TH/WB

04/14/2014

7.NAME (Last, First, Middle Initial)

4. ID TYPE

8. GRADE/RATE

ACG-THERAPEUTIC, DONOR

6. CHAGAS

13. ABO/Rh

9. DATE OF BIRTH

10. AGE

11. SEX

01/01/1980

34 Yr 3 Mo

F

14. CURRENT MAILING ADDRESS

15. COUNTRY

123 TEST LANE, ALEXANDRIA, VA, 22304

United States

18. ORGANIZATION

5. ID NUMBER

16. DUTY PHONE

12. ETHNICITY

17. BEST CONTACT PHONE

19. STATION

20. Total Donations

21. DONOR ID

2

SECTION III

22. DEFERRAL
LIST CHECKED BY

23. DONOR ID
VERIFIED BY

24 WEIGHT

ACA001

ACA001

160

31.VITAL SIGNS MONITOR

YES

NO

26. PULSE

27. BP

28. HGB/HCT

29. ARM CHECK

98

66

120/80

14 / TNP

SAT

TECH:

TECH:

TECH:

TECH:

TECH:

ACA001

ACA001

ACA001

ACA001

ACA001

32. HEMOGLOBINOMETER

34. DOES DONOR QUALIFY?

DN00000023

25. TEMP

30. GENERAL
APPEARANCE
SAT

33. SCALE

35. BAG LOT NO.

36. SEGMENT NO.

37. REVIEWER

TECH:

DONOR MEDICAL HISTORY
Question # Question

Response

Comment

201

Are you pregnant now, or have you been pregnant in the past 6
weeks?

Yes

Reviewed and Verified
by Screener

Are you feeling well and healthy today?

No

203

204

206

WELL

Have you ever had chest pain, heart disease, or lung disease?

History of pregnancy
within last 6 weeks.

Reviewed and Verified
by Screener

Donor misunderstood.
Meant to answer Yes.

Yes
HLCA

Have you seen your provider concerning this condition in the past 6
months?

Medically Acceptable
Heart/Lung Condition

Yes
HLCP6 Heart/Lung Phy Exam <
6 Months
Yes

Have you ever had fainting spells, convulsions or seizures?

M

205

SA

202

PREG

FCSA

Do you have a consult from your Provider?

History of Fainting,
Convulsions, Seizures Eligible

Yes
DATE

Reviewed and Verified
by Screener
Reviewed and Verified
by Screener
Reviewed and Verified
by Screener

Reviewed and Verified
by Screener

Consult Date.

PL
E

SECTION IV

38. START TIME

39. STOP TIME

40. PHLEBOTOMIST

41. DONATION STATUS
COMPLETE

42. REACTION

UNSUCCESSFUL

INCOMPLETE

OVERFILL

NONE

SLIGHT
MODERATE

SEVERE