Phone order documentation.

[Nursing 1980]

Throughout my nursing practice, I noticed many different ways of documenting dose change in phone order. I want to discuss with others about the best way to document dose change.

At page 24, National Residential Medication Chart:

https://www.safetyandquality.gov.au/sites/default/files/migrated/SAQ123_NursesUserGuide_V6.pdf

The phone order contains the following fields:

Medicine. Strength. Dose. Route. Frequency. Start date. Stop date.

Reason ordered. Additional instructions.

Nurse signature 1, Date. Nurse Signature 2, Date.
Prescriber name, Prescriber signature, Date.

For example, if there is a phone order about dose change from Amoxillian 250 mg to 500 mg (notes: it is only an example), two ways to document are as follows:

1.

Medicine: Amoxcillian. Strength: 500 mg tab. Dose: 500 mg. Route: PO. Frequency: TDS.

Reason ordered: UTI. Additional instructions: Cease Amoxcillian 250 mg.

2.

Medicine: Amoxcillian. Strength: 250 mg tab. Dose: . Route: . Frequency: .

Reason ordered: Ceased due to dose change.

Medicine: Amoxcillian. Strength: 500 mg tab. Dose: 500 mg. Route: PO. Frequency: TDS.

Reason ordered: UTI.

In my opinion, the first way is more neat. The second way is more complete. However, which way is more accurate?

[Nursing 1980]

To make it simple, how do others document dose change in phone order at their facilities?

[sparticus2008]

Can't really answer your questions because where I work we never take a phone order for a dose change.
We only take phone orders for a once off stat dose of a medication & these are written in the specific area at the front of the med chart