PHWB Report — CENTEX RAC

01 Agency & Identifiers

Agency *

Incident Date *

Wristband # * Must start with "TX"

Hospital MRN

02 Incident Timeline

PSAP Time

Dispatch Time

Scene Arrival Time

Arrival to Patient (time)

Leave Scene Time

Transfer to Other Pre-Hospital Agency

Time at Destination

Transfer of Care

03 Patient Information

Sex *

Race

Weight (kg)

Transport Method *

Primary Impression *

04 Initial Vitals

Initial GCS Range 3–15

Initial SBP

Initial DBP

Initial HR

Initial Shock Index (auto)

Initial RR

Initial SPO2

Initial ETCO2

05 Blood Administration

WB Given? *

Consent Obtained?

Date/Time Taken (from Blood Bank)

Time Blood Started

Blood Given Warmed?

Blood Type Given

Total Number of Units Given *

WB Unit #

Total PRBCs

PRBC #

Total Plasma

Plasma #

GCS Prior to Start of Blood

Other Forms of Hemorrhage Control

06 Outcomes & Adjuncts

Pre-Hospital Cardiac Arrest?

Expired Prior to ED Arrival?

TXA Administered?

Calcium Administered?

Transfusion Reaction?

07 Final Vitals

Time of Final VS

Final SBP

Final DBP

Final HR

Final Shock Index (auto)

Final RR

Final SPO2

Final ETCO2

All submitted data is transmitted securely and stored in the CENTEX RAC PHWB reporting system. Fields marked * are required.

Pre-Hospital Whole Blood Report

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