To standardize the Pathology Doctor’s Order forms and to meet regulatory requirements, a new form has been approved for use in requesting blood bank tests and blood components. The Blood Center Request A-1a Pathology Doctor’s Order is now available from Stores (MB01366) and will replace the Blood Center Request Form 57. NOTE: This new form will NOT replace the need to write a separate order for transfusion on the A-1a Doctor’s Order.

Although the size and design of the new form A-1a gives it a very different appearance, the content is essentially the same. A summary of the changes is listed below:

1. The new request is a full-sized, two part form similar to other A-1a Pathology Doctor’s Order forms currently used for laboratory tests. As with other Pathology A-1a forms, the original should be sent to the Blood Bank and the copy placed in the medical record.

2. The Typenex sticker is applied to the upper left hand corner on the top copy of the form in the designated area.

3. To comply with the two signature requirement, there is a place designated for witness signature in addition to phlebotomist signature.

4. Please provide a weight for pediatric patients when blood components are requested.

5. There is a place to provide ICD-9-CM codes.

Please replace existing stock of Form 57 with the new A-1a form. If you have any questions regarding the use of the form, please contact the Blood Bank (6-2561).