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DOCUMENTATION AND RECORD KEEPING R.RAJKUMAR

Definition of Documentation. All written procedures, instructions, records, test results, quality control procedures involved in providing effective transfusion services.. Definition . Standard operating procedures (SOPs)Written instructions for the performance of a specific procedure.E.g- SOPs

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DOCUMENTATION AND RECORD KEEPING R.RAJKUMAR

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    1. DOCUMENTATION AND RECORD KEEPING R.RAJKUMAR TRG MEMBER – NACO SOUTH ZONE

    2. Definition of Documentation All written procedures, instructions, records, test results, quality control procedures involved in providing effective transfusion services.

    3. Definition Standard operating procedures (SOPs) Written instructions for the performance of a specific procedure. E.g- SOPs for donor recruitment, donor care, TTI Testing, QC Testing etc. Records Documents stating evidence of activities performed & results achieved. E.g.: Donor records, test records, training records, Equipment maintenance records and Transfusion records.

    4. OBJECTIVES OF DOCUMENTATION Easy availability of information For improved operations For providing quality service Stoppage of wastage

    5. VALUE OF DOCUMENTATION Helps in making decisions. Investigates problems & errors - rectification Ensures records & outcomes are traceable Processes can be audited. Tool for training programmes. Improves efficiency.

    6. Purpose of Documentation To create statistics To retain blood donors To maintain panel donors To recognize & to give awards To undertake any research activity To help during emergency To protect the interest of the patients

    7. TYPES OF DOCUMENTATION Policies Manuals Standard Operating procedures. Specifications. Data Sheets. Forms. Records. Standards Labels.

    8. RECORD KEEPING Systematic procedure by which the records of an organisation are created, captured, maintained and disposed off. This system also ensures their preservation for evidential purposes, accurate and efficient updating, timely availability and control of access to them only by authorised personnel.

    9. Record keeping includes Process of Donor Selection Collection of Donated Blood Donor Screening Laboratory Testing Processing and Storage Matching and Issue for transfusion Disposable system

    10. S.O.P STANDARD OPERATING PROCEDURES SUITABLE OPTIONAL PRACTICES

    11. Objectives of Record Keeping To improve upon the day to day work of the Blood Bank To help promotion of voluntary blood donation To provide information of donor’s profile To monitor availability, distribution and utilisation of blood

    12. Standard Operating Procedures Standard Operating Procedures (SOPs) are a very important part of the Quality Assurance System. An SOP is a document that specifies the way that a particular task should be undertaken within a particular work area. Each transfusion service should have a number of SOPs covering all the procedures that are undertaken from vein to vein. SOPs are not simply guidelines to help the staff to perform particular tasks. They are written instructions that should be followed by all strictly at all times by maintaining confidentiality.

    13. Importance of SOP If SOP is followed strictly – all procedures are performed exactly in a same manner. No deviations and errors Because of Standards, monitoring the process becomes very easy It simplifies and standardizes the training of staff Reduce adverse effects on performance when any change of personnel occurs It can be used to assist in resolving disputed issues if there is any legal action taken.

    14. Documentation by whom By the Donors By the Donor Organisers By the Donor Organisation By the Donor Motivator By the NGOs By the Blood Banks By the Government authorities By the SACS / SBTC

    15. Methodology Simple and clear Systematic Relevant information only Fully completed User friendly Quick retrieval of information Categorized – open doc. / closed doc. Accessible

    16. Documentation records of Blood Donors in Camps Number of people turned Eligible Donors / Donors Screened Deferred Donors – with reasons Donors Donated Blood First time / Regular / Occasional / Frequent Rare blood donors Blood Group wise donors Age group wise donors Male & Female Donors Employed & Unemployed

    17. Essential Donor Information Name Age Date of Birth Weight Sex Date of donation Address – office Address – residence Telephone /s Mobile number Fax if any E-mail Blood group Rh factor Frequency of donation Preference dates Identity number if any Consent of the donor Any other information

    18. Record Keeping by NGOs Donor information – A to Z Important and Preferable dates Preferable Blood Banks Psychology of donors & their timings Confidentiality of donors Rare blood group records separately Special donors records

    19. Documentation in Blood Banks Donors Records – A to Z Blood Bag Records Consumables and stock register Blood Components records Selection / Collection / Screening Issuing and Discard of blood units record Storage / Usage / Disposal of records

    20. Constraints of Documentation Repetition of data in many areas Negative Donors are targeted Directory of Donors Updating of donor records Confidentiality When the object of the organisation changes

    21. Panel donors Donors who have donated blood for more than 3 times or who have donated blood on call during emergency or on their own at regular intervals can be categorized under panel donor system

    22. Importance of Panel Donors Screened regularly / understand the importance of health /risk behaviour factor. Experience in giving blood and can be dealt with more quickly Dependable & willing to donate during emergency as well as on regular basis They provide basic source of safe blood

    23. A case study Indian Bank Blood Donation Move Donor Names maintained branch wise and blood group wise Date and place of donation updated regularly on every donation Every branch had one co-ordinator for getting blood donors with branch records Awards to the donors for more than 5 /10 /15/ 20 /25 /50 etc during annual function Branches contributing more than 100 donors will be awarded with a shield. 23rd consecutive year maintaining NUMBER ONE for mobilising maximum number of blood donors in Tamilnadu

    24. Modern Technology Computerisation of data Usage of Web & Portals Net Working of Blood Banks & Sharing of information Soft copy with back up system

    25. Summary What is not documented is not done. Each activity and the outcome of each activity in BTS is documented. Documentation helps to ensure consistency of processes & procedures. Documentation gives traceability Good documentation indicates good quality system in BTS. Accurate donor records help in developing a panel of regular donors.

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