Sample ABLA Query Form

Acute Blood Loss Anemia Query Template

Sample ABLA query form

Documentation in the medical record indicates the following:  

• Diagnosis of Anemia [include type]  
• Drop in Hct/Hgb from______ to____
• Blood transfusion of xxx units  
• GI Bleeding [or other hemorrhage]  
• Other:

Based on your medical judgment, can you further clarify in the progress notes the diagnosis
associated with these findings such as: 

• Acute blood loss anemia  
• Acute hemorrhagic anemia  
• Chronic blood loss anemia  
• Acute on chronic blood loss anemia  
• Iron deficiency anemia  
• Other anemia: (please specify)  
• None of the above / Not applicable

In responding to this request, please exercise your independent professional judgment. The 
fact that a question is asked does not imply that any particular diagnosis is desired or
expected.

Thank you!