RECORD REVIEW WORKSHEET Page 1 0 ) ble esi rd n-o ff b od yM ilut Do ed bef em n-h ro Se 0 gn shi ore if a do cum ed uir req er 0 ee p lica 0 ent tes lica app HT RP 0 Oth B 0 R VA g HC sA HB 0 LVI/II (if HIV nd 1a 0 ts ( ble ) ue 2 hT iss wit 0 HIV rol Se Co nse og nt ies Re dy Bo 0 pp gun dd frig era c, P res eat h, E nu fD D/T To D/ Au 0 tion &A c er So /Co ME top sy/ vie Re 0 Sig 0 Be w 0 ron ed/ ses CO Ch D, art Ph DO B ysi cal w, M As por if im B( e/ 0 Re ent sm ) ted 0 Ag So urc iqu Un 0 No 0 eE am BN tE ort 0 Dis Imp Lo cal 0 vie e on Ph .& Record Review Worksheet June 2016 0 eD on or ID dd 0 Re se Date of Death arc h e, A Sub Total Tra nsp lan t Donor Number 'l P roc INSTRUCTIONS: 1. Review at least one record per month dating from the time of the last inspection. 2. Enter "0" for any item present and/or in compliance with the EBAA Medical Standards and enter "1" for any applicable item absent and/or not in compliance. 3. The results for each column will be automatically totaled as the numbers are entered. Then enter the totals on the Record Review Summary Form. Submit the Summary and this worksheet with the Inspection Questionnaire. 0 0 COMMENTS RECORD REVIEW WORKSHEET Page 2 Subtotal 0 Record Review Worksheet June 2016 0 0 0 0 0 0 0 ort ed s if ver se rea ctio n ativ e ery 0 rep tco me 0 Ad Po Typ e stO of per no cat io Lo 0 Su rg fS urg ery fS urg te o Da 0 Ou ery s osi Dia gn cip ien t Ag Re Re cip ien t eR iqu Un 0 ea nd ID 0 eci pie nt Na me Re rge on Su 0 cip ien t Na me of ide nce Ev 0 /or ty DO B gn tra cea bili nsi / co sur g of me Na 0 Re qu ee ain in eon i.e. ssu e: f ti l. o Uti 0 est g 0 sx, res , tr rt spo cle ato r, E val uat or En u me Na Inf Da te, o if Tim e Re tur &M ned eth o and sol u age sto r 0 dT ran lot tio n& plic abl e) Do Typ e no of rc ult ure s (i app f ap lica ble add etr y, i f chy m Pa 0 Re dis trib # roc 'l p roc 'l p exc .& add ecu lar p Sp Sli 0 ost st e xc. & po t la mp ht nlig Donor Number Pe ISB T1 28 Tis sue Ide nt. per Gra ft exa mp enu rior t cle o ex atio c n ision o r ute d INSTRUCTIONS: 1. Review at least one record per month dating from the time of the last inspection. 2. Enter "0" for any item present and/or in compliance with the EBAA Medical Standards or enter "1" for any applicable item absent and/or not in compliance. 3. The results for each column will be automatically totaled as the numbers are entered. Then enter the totals on the Record Review Summary Form. Submit the Summary and this worksheet with the Inspection Questionnaire. 0 COMMENTS
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