Reconcile Medications at Discharge (Side-By-Side)

See also: Overview of the Discharge Medications Comparison Lists
This form can be completed by an MD, PA, NP, RN, or medical student. If completed by an RN or medical student, it must be cosigned. For additional information, see the Overview of Discharge Orders, Instructions, and the Patient Care Referral Form.
Changes made to discharge medication orders trigger an alert for clinicians if the Patient Discharge Medications List (PDML) has already been saved and printed. See Handling the Notifications When Medications Have Changed After PDML Print. The Order Status for patients whose PDML may require reprinting is Discharge (in red).
Face Sheet Discharge Orders and Instructions are not available in the newborn nurseries. You cannot access the forms, even if you select a patient from the associated maternity unit lists or from patient lookup.

If you haven't already:

Select the patient and click Face Sheet Discharge (ALT+F) or Discharge (ALT+G).
If needed, click the Medications folder to access the form.

When available for the selected patient's care unit, the Patient Discharge Medication List (PDML) is generated automatically. If prompted, click one of the buttons at the bottom of the message to continue:

Remind Me Later (ALT+R)—The message will be closed, and presented whenever you open the Medications folder in Discharge.
Close and Don't Remind Me (ALT+C)—The message will be closed and never presented again.

Reconcile pre-admission (PAML), inpatient, and discharge medication orders—Side-by-side comparison

Discharge orders cannot be signed as final (that is, "the patient is ready to go") until the PAML is signed as PAML Creation: Complete, and the discharge reconciliation is completed. Each order listed must be reconciled by indicating whether it is to be included as a discharge order.

See

For each medication in the Pre-Admission Medications list (which is populated from the PAML builder):

Click the checkbox in either the Yes or No column to indicate whether the order should be resumed in the discharge orders.
On clicking Yes for orders to be resumed, the medication order form opens, pre-populated with all information that is available from the PAML record. Complete the order and click OK (ALT+O). See Writing Medication Orders.
On resuming an oral chemotherapy medication, you are notified that this is an order for chemotherapy that should be reviewed with the patient's oncologist. Click OK (ALT+O) to acknowledge the message.

For medications where the name, route, dose, frequency, and PRN status (yes or no, not reason) are the same , clicking Yes or No on one side (pre-admission or inpatient) automatically checks the same response for that medication on the other side (inpatient or pre-admission).

For each medication in the Current Inpatient Medications list:

Click the checkbox in either the Yes or No column to indicate whether the order should be continued in the discharge orders.
On clicking Yes for orders to be continued, the medication order is copied to the Discharge Medications list below. See Editing medication orders for discharge.
On selecting Yes to continue a taper order through discharge, you are notified that the selected order has scheduled doses over a limited duration. Click Continue Scheduled Taper to add the discharge order with the same exact schedule, or Edit Taper to make changes that will account for doses given in-house.
On selecting Yes to continue a duration order through discharge, you are notified that the selected order has scheduled doses over a limited duration. Click Continue Scheduled Duration to add the discharge order with the same exact schedule, or Edit Duration to make changes that will account for doses given in-house.
On opening discharge orders, when the eMAR (electronic medication administration record) determines that doses of a duration or taper medication have been given since the discharge order was continued from the inpatient order, you are prompted to edit the discharge medication order, or to update the discharge order to account for the doses given in-house. If ALL doses have been given, you are prompted to edit or remove the order from discharge.
If you click Yes and there are unreconciled free-text PAML medications, you will be prompted to indicate whether the discharge order is intended to replace a free-text PAML medication. See Manually Matching Free-Text PAML Meds at Discharge.
On selecting Yes for an insulin order that includes NPO dosing, you are prompted to reconcile the NPO dose. Click Yes to include the NPO dose as a separate order for discharge, with instructions for the patient to take that dose when not eating. The main part of the original order is copied as a discharge order with instructions to take when eating. Click No to include only the main (non-NPO) order, without instructions related to diet.

To make it easier to see more records when the medications lists are long, either pane—Medications to Reconcile or Discharge Medications List—can be enlarged:

	Click to enlarge Medications to Reconcile pane
	Click to restore Medications to Reconcile pane to the top 2/3 of the display
	Click to enlarge the Discharge Medication List pane
	Click to restore Discharge Medication List pane to the bottom third of the display

Clicking a folder in the discharge orders/instructions set on the left opens the applicable discharge order/instructions page; click the Medications folder to return to the reconciliation/discharge medications lists.
To add or edit instructions that will print on the PDML (Patient Discharge Medications List), click the Instructions field for the order. Type instructions when prompted, then click OK (ALT+O). See Writing Instructions for a Discharge Medication.

See also: