Affix Patient Label Here

	Trauma and MTP Response Log	

Patient Name:

	Return Time:	Responding TSL Tech(s):	2nd TSL Tech/Time	
Hospital ID#:	Date of Birth or Approx. Age:	Clinical trial:  No
ATLAS      PROPPR	 Gender: (circle)
 Male   /    Female 	
Date/Time ABO/Rh sample collected:  	MTP activated?
(circle)   Yes / No	Date/Time MTP activated:	Response Date & Time: 	

Stock Blood Products: 

Unit Number:	Blood Product TYPE	
Date/Time Issued:
(to patient)	Date/Time Returned 
to Refrigerator	Units Not Given          Returned to Inventory                              by TSL Tech Time/Date	Issued in Sunquest by   TSL Tech Time/Date	
	RBC 
(Units)	Plasma
(Units)	Platelets 
(Doses)	Cryo
(Units)					

									

									

Patient Diagnosis/Clinical Information: (Include Medic #/Patient ED Admission #).	

	

Patient Disposition:	

Lab Results:
Time Sent	Hematocrit*	PT*	INR*	Fibrinogen*	Platelet Count*	Hemoglobin	Other (Test Name, Result)	

								

								
* Emergency Hemorrhage Panel (EHP) Results