July 2010: Reconciling PAML Free-text Records at Discharge
Starting in mid-July, providers writing medication orders for discharge are prompted to consider whether new orders are reconcilable with any existing "free-text" entries on the patient's pre-admission medication list. When it is matched manually to a discharge order, the free-text medication is not listed as "Stop taking" on the patient's discharge medication instructions.
Free-text or take-as-typed entries on the PAML exist when the provider who built the list did not select the medication from the defined medication list for the institution. These uncoded entries cannot be checked by the order entry system against any other data, including patient allergies, drug-drug interactions, or medication orders written for the inpatient stay or for discharge. The provider writing discharge orders must manually review free-text entries to complete the medication reconciliation.
Key features:
Triggering the prompt:
The patient has one or more unreconciled free-text medications in the PAML
Ordering a new discharge medication
Continuing a current inpatient medication
Prompt the ordering provider to indicate whether the medication being ordered replaces one of the free-text PAML medications
If the ordering provider selects a free-text medication when prompted, the free-text medication is reconciled as a source of the new discharge order
If the free-text PAML medication is matched to an inpatient order that is continued at discharge, the free-text PAML medication and the selected inpatient medication are electronically linked as matching medications
Demonstration: Reconciling Free-Text PAML Medications at Discharge
Instructions: See Discharge Medications: Reconciling Free-Text Pre-Admit Meds
See also: