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Phone order documentation.

Australia   (243 Views 2 Comments)
by Nursing 1980 Nursing 1980 (New) New Nurse

147 Profile Views; 9 Posts

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?

 

 

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9 Posts; 147 Profile Views

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

 

Edited by Nursing 1980

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