|Mnemonic: ||[AUTO COLL]|
|Name: ||Autologous RBC Collection|
|Note: ||Outpatients: Donations are scheduled in advance with the American Red Cross. Refer to the link below for complete ordering information and patient guidelines.|
Guidelines for completing American Red Cross Special Collections Order:
Section A: Patient Information Record
--Information submitted must be legible.
--List the patientís full name, exactly as the patient is registered at the hospital.
--Include the patientís home phone number and an alternative number, if available.
--List the patientís mailing address.
Section B: Physicianís Order
--Specify the Donation Type: Autologous, Directed or Both.
--Indicate the Unit Type and the Number of Units to be collected.
--Indicate test for CMV*, Leuko-reduce, or irradiate, as necessary.
* CMV (cytomegalovirus) testing may be requested for directed donations, if desired. CM V testing is not requested for Autologous donors unless the patient is a bone marrow donor.
Section C: Physicianís Pre-assessment of the Autologous Donor:
--Check all past or present medical conditions of the donor.
--The Special Collections Staff will contact the patientís cardiologist of primary care physician if your patient has a history of Cardiac/Cardiovascular Disease. The cardiologist or primary care physician would then be asked to complete Section E of the Special Collection Order.
--Indicate if your patient has any restriction of physical activity.
--List the patientís current medications.
Section D: Ordering Physicianís Information
--The Transfusion Date is the Scheduled Surgery Date.
--The Transfusion Service/Hospital is the facility in which the surgery is scheduled
--The Ordering Surgeon must sign and date the order.
--The Special Collections Department must be notified of any changes.
Please contact the Special Collection Staff, by phone, at 1-888-808-4918, if you have any questions regarding Special Collections Donations
For more information about autologous and directed donations:
American Red Cross Special Collections Order Form