Hospital PHWB Report

Every question here is Essential under the program spec, but only the six marked * are enforced at submit. Fill in everything you have — when you submit, you'll get a summary of anything left blank and can either go back or send the record as-is. A partial report is far more useful to the RAC than no report.

01 Facility & Case Linkage

Facility *

Hospital Arrival Date *

Wristband # Links this record to the EMS pre-hospital report

Hospital MRN

02 Arrival & Demographics

1. Hospital Arrival Location *

ED Bypassed ED (direct to OR)

Selecting "Bypassed ED" re-labels the ED questions below to "OR" and hides the ED-only MTP questions.

12. Patient Blood Type

13. Was RhIG given?

No Yes

03 Initial ED Vitals

2. Initial ED Respiratory Rate (RR)

3. Initial ED Heart Rate (HR)

4. Initial ED Systolic BP (SBP)

5. Initial ED Diastolic BP (DBP)

6. Initial ED Shock Index (auto)

7. Initial ED SPO2

8. Initial ED ETCO2

04 Massive Transfusion Protocol

9. Was Massive Transfusion Protocol (MTP) activated in the ED?

No Yes

10. Was blood given either as ER release or MTP?

No Yes

11. Was TXA administered to the patient in the ED?

No Yes

05 ED Interventions — Blood Products

14. Indicate all blood product types given in the ED *

Whole Blood Packed Red Blood Cells Plasma Platelets Cryoprecipitate None

Select every product administered. Unit-count questions below appear based on what you select.

15. Total Whole Blood units given in the hospital

16. Whole Blood Unit Number

17. Total Packed Red Blood Cell units given in the hospital

18. Packed Red Blood Cell Unit Number

19. Total Plasma units given in the hospital

20. Plasma Unit Number

06 ED Outcome

21. ED disposition — where did the patient go after the ED?

07 Indication & Mechanism

22. Indication for Blood Transfusion *

23. Blunt mechanism

24. Penetrating injury mechanism

08 Hospital Stay

25. Hospital length of stay (days)

26. Number of ICU days

27. ICU Free Days (auto)

09 Hospital Outcome

28. Did the patient develop a transfusion reaction?

No Yes

29. 48-Hour Disposition *

30. Did death occur within the first 24 hours of admission?

No Yes

31. Indicate death location

32. Was primary cause of death hemorrhage?

All submitted data is transmitted securely and stored in the CENTEX RAC hospital whole blood reporting sheet. It is not published to the public site. Fields marked * are required.

Hospital Whole Blood Report

Submission Not Confirmed

Report Received