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| Hemodilution Worksheet |
| Referral Information |
| EBSR Referral ID: {if(is_empty(refinfo_SQ001.NAOK)," ---",refinfo_SQ001.shown)} | DIN: {if(is_empty(refinfo_SQ002.NAOK)," ---",refinfo_SQ002.shown)} | OPO ID: {if(is_empty(refinfo_SQ005.NAOK)," ---",refinfo_SQ005.shown)} |
| Technician Name |
| First Name: {if(is_empty(techname_SQ001.NAOK)," ---",techname_SQ001.shown)} | Last Name: {if(is_empty(techname_SQ002.NAOK)," ---",techname_SQ002.shown)} | Tech Code: {if(is_empty(techname_SQ003.NAOK)," ---",techname_SQ003.shown)} |
| Phlebotomy |
| Blood Loss: {if(is_empty(bloodloss.shown),"---",bloodloss.shown)} | Transfusion/Infusion Status: {if(is_empty(stype2.shown),"---",stype2.shown)} |
| Specimen Type: {if(is_empty(stype.shown),"---",stype.shown)} | Donor Weight in kg: {if(is_empty(dweight.shown),"---",dweight.shown)} |
| Blood Sample Done By: | {if(is_empty(ebsr.shown),"---",ebsr.shown)} {ebsr_comment.NAOK} |
| Tracking Number: {tnum.NAOK} |
| Blood Sample Site: {if(is_empty(vsite_SQ001.NAOK)," ---",vsite_SQ001.shown)} {vsite_SQ001comment.NAOK} {if(is_empty(vsite_SQ002.NAOK)," ---",vsite_SQ002.shown)} {vsite_SQ002comment.NAOK} {if(is_empty(vsite_SQ003.NAOK)," ---",vsite_SQ003.shown)} {vsite_SQ003comment.NAOK} {if(is_empty(vsite_SQ004.NAOK)," ---",vsite_SQ004.shown)} {vsite_SQ004comment.NAOK} |
| Vacutainer Type | Lot Number | Exp Date | Collection Date | Collection Time |
| {if(is_empty(vtype.shown),"---",vtype.shown)} | {if(is_empty(lot.shown),"---",lot.shown)} | {if(is_empty(exp.shown),"---",exp.shown)} | {if(is_empty(coldate.shown),"---",coldate.shown)} | {if(is_empty(ctime.shown),"---",ctime.shown)} |
| {if(is_empty(vtype2.shown),"---",vtype2.shown)} | {if(is_empty(lot2.shown),"---",lot2.shown)} | {if(is_empty(exp2.shown),"---",exp2.shown)} | {if(is_empty(coldate2.shown),"---",coldate2.shown)} | {if(is_empty(ctime2.shown),"---",ctime2.shown)} |
| {if(is_empty(vtype3.shown),"---",vtype3.shown)} | {if(is_empty(lot3.shown),"---",lot3.shown)} | {if(is_empty(exp3.shown),"---",exp3.shown)} | {if(is_empty(coldate3.shown),"---",coldate3.shown)} | {if(is_empty(ctime3.shown),"---",ctime3.shown)} |
| {if(is_empty(vtype4.shown),"---",vtype4.shown)} | {if(is_empty(lot4.shown),"---",lot4.shown)} | {if(is_empty(exp4.shown),"---",exp4.shown)} | {if(is_empty(coldate4.shown),"---",coldate4.shown)} | {if(is_empty(ctime4.shown),"---",ctime4.shown)} |
| Total Number of Vacutainers: {if(is_empty(numv.shown),"---",numv.shown)} |
The Eye-Bank For Sight Restoration|120 Wall Street New York,NY,10005|V-04.11.2022-2.0-VL
DIN: {if(is_empty(refinfo_SQ002.NAOK)," ---",refinfo_SQ002.shown)} | Technician: {if(is_empty(techname_SQ001.shown),"---",techname_SQ001.shown)} {if(is_empty(techname_SQ002.shown),"---",techname_SQ002.shown)} | Signed: {date("F d, Y",strtotime('-4 hours'))} {date('H:i', strtotime(date("H:i")))}
| A. Blood Transfusion |
| Date | Time | Product | Quantity(ml) |
| {if(is_empty(date.shown),"---",date.shown)} | {if(is_empty(time.shown),"---",time.shown)} | {if(is_empty(product.shown),"---",product.shown)} | {if(is_empty(quantity.shown),"---",quantity.shown)} |
| {if(is_empty(date1.shown),"---",date1.shown)} | {if(is_empty(time1.shown),"---",time1.shown)} | {if(is_empty(product1.shown),"---",product1.shown)} | {if(is_empty(quantity1.shown),"---",quantity1.shown)} |
| {if(is_empty(date2.shown),"---",date2.shown)} | {if(is_empty(time2.shown),"---",time2.shown)} | {if(is_empty(product2.shown),"---",product2.shown)} | {if(is_empty(quantity2.shown),"---",quantity2.shown)} |
| {if(is_empty(date3.shown),"---",date3.shown)} | {if(is_empty(time3.shown),"---",time3.shown)} | {if(is_empty(product3.shown),"---",product3.shown)} | {if(is_empty(quantity3.shown),"---",quantity3.shown)} |
| {if(is_empty(date4.shown),"---",date4.shown)} | {if(is_empty(time4.shown),"---",time4.shown)} | {if(is_empty(product4.shown),"---",product4.shown)} | {if(is_empty(quantity4.shown),"---",quantity4.shown)} |
| {if(is_empty(date5.shown),"---",date5.shown)} | {if(is_empty(time5.shown),"---",time5.shown)} | {if(is_empty(product5.shown),"---",product5.shown)} | {if(is_empty(quantity5.shown),"---",quantity5.shown)} |
| {if(is_empty(date6.shown),"---",date6.shown)} | {if(is_empty(time6.shown),"---",time6.shown)} | {if(is_empty(product6.shown),"---",product6.shown)} | {if(is_empty(quantity6.shown),"---",quantity6.shown)} |
| {if(is_empty(date7.shown),"---",date7.shown)} | {if(is_empty(time7.shown),"---",time7.shown)} | {if(is_empty(product7.shown),"---",product7.shown)} | {if(is_empty(quantity7.shown),"---",quantity7.shown)} |
| {if(is_empty(date8.shown),"---",date8.shown)} | {if(is_empty(time8.shown),"---",time8.shown)} | {if(is_empty(product8.shown),"---",product8.shown)} | {if(is_empty(quantity8.shown),"---",quantity8.shown)} |
| {if(is_empty(atotal.shown),"0",atotal.shown)} |
The Eye-Bank For Sight Restoration|120 Wall Street New York,NY,10005|V-04.11.2022-2.0-VL
DIN: {if(is_empty(refinfo_SQ002.NAOK)," ---",refinfo_SQ002.shown)}| Technician: {if(is_empty(techname_SQ001.shown),"---",techname_SQ001.shown)} {if(is_empty(techname_SQ002.shown),"---",techname_SQ002.shown)} | Signed: {date("F d, Y",strtotime('-4 hours'))} {date('H:i', strtotime(date("H:i")))}
| Hemodilution Worksheet |
| Blood Loss: {if(is_empty(bloodloss.shown),"---",bloodloss.shown)} | Transfusion/Infusion Status: {if(is_empty(stype2.shown),"---",stype2.shown)} |
| Specimen Type: {if(is_empty(stype.shown),"---",stype.shown)} | Donor Weight in kg: {if(is_empty(dweight.shown),"---",dweight.shown)} |
| B. Colloids Infused |
| Date | Time | Product | Quantity(ml) |
| {if(is_empty(date13.shown),"---",date13.shown)} | {if(is_empty(time13.shown),"---",time13.shown)} | {if(is_empty(product13.shown),"---",product13.shown)} | {if(is_empty(quantity13.shown),"---",quantity13.shown)} |
| {if(is_empty(date14.shown),"---",date14.shown)} | {if(is_empty(time14.shown),"---",time14.shown)} | {if(is_empty(product14.shown),"---",product14.shown)} | {if(is_empty(quantity14.shown),"---",quantity14.shown)} |
| {if(is_empty(date15.shown),"---",date15.shown)} | {if(is_empty(time15.shown),"---",time15.shown)} | {if(is_empty(product15.shown),"---",product15.shown)} | {if(is_empty(quantity15.shown),"---",quantity15.shown)} |
| {if(is_empty(date16.shown),"---",date16.shown)} | {if(is_empty(time16.shown),"---",time16.shown)} | {if(is_empty(product16.shown),"---",product16.shown)} | {if(is_empty(quantity16.shown),"---",quantity16.shown)} |
| {if(is_empty(date17.shown),"---",date17.shown)} | {if(is_empty(time17.shown),"---",time17.shown)} | {if(is_empty(product17.shown),"---",product17.shown)} | {if(is_empty(quantity17.shown),"---",quantity17.shown)} |
| {if(is_empty(date18.shown),"---",date18.shown)} | {if(is_empty(time18.shown),"---",time18.shown)} | {if(is_empty(product18.shown),"---",product18.shown)} | {if(is_empty(quantity18.shown),"---",quantity18.shown)} |
| {if(is_empty(date19.shown),"---",date19.shown)} | {if(is_empty(time19.shown),"---",time19.shown)} | {if(is_empty(product19.shown),"---",product19.shown)} | {if(is_empty(quantity19.shown),"---",quantity19.shown)} |
| {if(is_empty(date20.shown),"---",date20.shown)} | {if(is_empty(time20.shown),"---",time20.shown)} | {if(is_empty(product20.shown),"---",product20.shown)} | {if(is_empty(quantity20.shown),"---",quantity20.shown)} |
| {if(is_empty(date21.shown),"---",date21.shown)} | {if(is_empty(time21.shown),"---",time8.shown)} | {if(is_empty(product21.shown),"---",product21.shown)} | {if(is_empty(quantity21.shown),"---",quantity21.shown)} |
| {if(is_empty(btotal.shown),"0",btotal.shown)} |
The Eye-Bank For Sight Restoration|120 Wall Street New York,NY,10005|V-04.11.2022-2.0-VL
DIN: {if(is_empty(refinfo_SQ002.NAOK)," ---",refinfo_SQ002.shown)} | Technician: {if(is_empty(techname_SQ001.shown),"---",techname_SQ001.shown)} {if(is_empty(techname_SQ002.shown),"---",techname_SQ002.shown)} | Signed: {date("F d, Y",strtotime('-4 hours'))} {date('H:i', strtotime(date("H:i")))}
| Hemodilution Worksheet |
| Blood Loss: {if(is_empty(bloodloss.shown),"---",bloodloss.shown)} | Transfusion/Infusion Status: {if(is_empty(stype2.shown),"---",stype2.shown)} |
| Specimen Type: {if(is_empty(stype.shown),"---",stype.shown)} | Donor Weight in kg: {if(is_empty(dweight.shown),"---",dweight.shown)} |
| C. Crystalloids Infused |
| Date | Time | Product | Quantity(ml) |
| {if(is_empty(date26.shown),"---",date26.shown)} | {if(is_empty(date26.shown),"---",date26.shown)} | {if(is_empty(product26.shown),"---",product26.shown)} | {if(is_empty(quantity26.shown),"---",quantity26.shown)} |
| {if(is_empty(date27.shown),"---",date27.shown)} | {if(is_empty(date27.shown),"---",date27.shown)} | {if(is_empty(product27.shown),"---",product27.shown)} | {if(is_empty(quantity27.shown),"---",quantity27.shown)} |
| {if(is_empty(date28.shown),"---",date28.shown)} | {if(is_empty(time28.shown),"---",time28.shown)} | {if(is_empty(product28.shown),"---",product28.shown)} | {if(is_empty(quantity28.shown),"---",quantity28.shown)} |
| {if(is_empty(date29.shown),"---",date29.shown)} | {if(is_empty(time29.shown),"---",time29.shown)} | {if(is_empty(product29.shown),"---",product29.shown)} | {if(is_empty(quantity29.shown),"---",quantity29.shown)} |
| {if(is_empty(date30.shown),"---",date30.shown)} | {if(is_empty(time30.shown),"---",time30.shown)} | {if(is_empty(product30.shown),"---",product30.shown)} | {if(is_empty(quantity30.shown),"---",quantity30.shown)} |
| {if(is_empty(date31.shown),"---",date31.shown)} | {if(is_empty(time31.shown),"---",time31.shown)} | {if(is_empty(product31.shown),"---",product31.shown)} | {if(is_empty(quantity31.shown),"---",quantity31.shown)} |
| {if(is_empty(date32.shown),"---",date32.shown)} | {if(is_empty(time32.shown),"---",time32.shown)} | {if(is_empty(product32.shown),"---",product32.shown)} | {if(is_empty(quantity32.shown),"---",quantity32.shown)} |
| {if(is_empty(date33.shown),"---",date33.shown)} | {if(is_empty(time33.shown),"---",time34.shown)} | {if(is_empty(product33.shown),"---",product33.shown)} | {if(is_empty(quantity33.shown),"---",quantity33.shown)} |
| {if(is_empty(date34.shown),"---",date34.shown)} | {if(is_empty(time34.shown),"---",time34.shown)} | {if(is_empty(product34.shown),"---",product34.shown)} | {if(is_empty(quantity34.shown),"---",quantity34.shown)} |
| {if(is_empty(ctotal.NAOK),"0",ctotal.NAOK)} |
The Eye-Bank For Sight Restoration|120 Wall Street New York,NY,10005|V-04.11.2022-2.0-VL
DIN: {if(is_empty(refinfo_SQ002.NAOK)," ---",refinfo_SQ002.shown)} | Technician: {if(is_empty(techname_SQ001.shown),"---",techname_SQ001.shown)} {if(is_empty(techname_SQ002.shown),"---",techname_SQ002.shown)} | Signed: {date("F d, Y",strtotime('-4 hours'))} {date('H:i', strtotime(date("H:i")))}
| Hemodilution Worksheet |
| Blood Loss: {if(is_empty(bloodloss.shown),"---",bloodloss.shown)} | Transfusion/Infusion Status: {if(is_empty(stype2.shown),"---",stype2.shown)} |
| Specimen Type: {if(is_empty(stype.shown),"---",stype.shown)} | Donor Weight in kg: {if(is_empty(dweight.shown),"---",dweight.shown)} |
| Hemodilution Summary | |
|
Blood Transfusion: |
{if(is_empty(atotal.shown),"0",atotal.shown)} |
|
Colloids Infused: |
{if(is_empty(btotal.shown),"0",btotal.shown)} |
| Crystalloids Infused: | {if(is_empty(ctotal.shown),"0",ctotal.shown)} |
| Acknowledgement |
I, {if(is_empty(techname_SQ001.NAOK),"---",techname_SQ001.shown)} {if(is_empty(techname_SQ002.NAOK),"---",techname_SQ002.shown)} , certify the Hemodilution worksheet has been completed according to my training following established EBSR Policy and Procedures. Any deviation from established EBSR Policy and Procedures will be documented below and reported to supervision.
{if(is_empty(acknowledgement.shown),"---",acknowledgement.shown)}
{if(is_empty(anotes.shown),"---",anotes.shown)}
| Document Completed by and Electronic Signature |
| Technician: | {if(is_empty(techname_SQ001.NAOK),"---",techname_SQ001.shown)} {if(is_empty(techname_SQ002.NAOK),"---",techname_SQ002.shown)} |
| Date/Time: | {date("F d, Y",strtotime('-4 hours'))} {date('H:i', strtotime(date("H:i")))} |
| Security Token: | VERIFIED |
| Station IP: | {ipaddress.shown} |
| EBSR ID: | {if(is_empty(refinfo_SQ001.NAOK)," ---",refinfo_SQ001.shown)} |
| DIN: | {if(is_empty(refinfo_SQ002.NAOK)," ---",refinfo_SQ002.shown)} |
| OPO#: | {if(is_empty(refinfo_SQ005.NAOK)," ---",refinfo_SQ005.shown)} |
The Eye-Bank For Sight Restoration|120 Wall Street New York,NY,10005|V-04.11.2022-2.0-VL
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