Building the Pre-Admission Medication List (PAML)

displays in the identification section for patients who are active with Anticoagulation Management Services. Click the icon to display treatment details. (This icon also displays in the upper right of the CAS, and from there provides links to send an email or page to the primary AMS nurse.)

Changes made to the PAML 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).

If you haven't already, select the patient.
Click Pre-Admit Med List.
When prompted, indicate whether the patient and/or caregiver has consented to allow access to Surescripts© data on prescriptions:

Click EMR + fill data if you obtained consent. With consent, any available Surescripts© data is included in the medication source list.
If you have not been able to obtain consent, click EMR only. The PAML builder will open, but the medication source list will not include Surescripts© data.
If you obtain consent later, click the patient consent link at the top of the list of meds from electronic sources to reopen the consent prompt, then click EMR + fill data.

The PAML Notification window lists enhancements to the PAML builder. Notifications display whenever you open the builder, for a set length of time after the enhancement upgrade.
To prevent the notification from displaying the next time you open the builder, click to check Do not show this notification again. When a new notification is available, it will display automatically.
Click Ok to close the notification window. If there is more than one active notification message—that is, if you have not checked "don't show me" and the message has not expired—the next active message will display.
The PAML Tip of the Day displays automatically on opening the PAML builder, unless the notification message is active. Click Show Tips to display the tip of the day at any time.
Tips are active only when the patient has been selected using an MGH medical record number (MRN).
To prevent the automatic display of the tip of the day when you open the PAML builder, click to uncheck Show "Tip of the Day" after starting PAML builder.
To prevent a particular tip from displaying, click to check Do not show this tip again.
To display a different tip, click Next Tip or Previous Tip.
If you check Do not show this tip again for every tip, then close the display, the Show tips button is inactivated.
Click Close to access the PAML builder.

Targeted clinical decision support in the PAML includes a notification for providers when the patient has potential duplicate therapies or medications that are categorized as high-risk.

High-Risk Medications

The Decision Support Alert appears automatically on opening the PAML for the first time for a visit when the patient has medications on the electronic source list that are categorized as high-risk.
To include a high-risk medication from the alert in the pre-admission meds list, click to select the Add to PAML option. The med order form opens automatically so you can complete the details such as route, dose, and frequency. See Changing records in the PAML below for instructions.
To dismiss a medication from the alert without adding it to the PAML, click its Patient not taking option.
Selecting either Add to PAML or Patient not taking removes the medication from the alert.
Once all of the medications are dealt with, the alert closes automatically.
If you don't have enough information to decide, clicking closes the alert.
Until all of the meds listed are removed by either adding to the PAML or selecting Patient not taking, the alert can be redisplayed by clicking the Decision Support Alert Summary link in the PAML heading.
Unresolved alerts do not prevent completion of the PAML.

Potential Duplicate Therapies

When the Planned Action on Admission for a medication on the PAML are set to continue, it is checked against all other meds on the PAML that are also set to continue. If concurrent administration of two or more medications either increases the potential for adverse effects, or does not benefit the patient more than giving fewer drugs, the meds are flagged as duplicate therapies: .
Clicking the for a med displays its Decision Support Alert. To display all medications with alerts, click the Decision Support Alert Summary link in the PAML heading. Information displayed for each medication includes which other med(s) the triggered the flag.
To dismiss the alert while allowing record to remain on the PAML for future consideration, click the option to Change Planned Action on Admission, then select a plan that does not involve continuing the medication.
To remove a medication from the alert without adding it to the PAML, click its Patient not taking option.
Once all of the medications displayed are dealt with, the alert closes automatically.
To close the summary without resolving the alerts, click Done.
Unresolved alerts do not prevent completion of the PAML. Ordering the duplicate therapies are for the inpatient visit will trigger an intervention. See Responding To Duplicate Therapy Warnings when ordering medications.

If a medication from the LMR has been reconciled, and the LMR reconciliation status is Not Taking or Taking Differently, the status is flagged in the medication source list:

= Not taking
= Taking differently
The flag is followed by any comments that were entered with the status update. See Reconciling Medications in the LMR.

Records that have been copied to the PAML from the source list are checked in the "P" (for PAML) column. (See Adding Records to the PAML - Add meds to the PAML from source list, below.) The check remains even if you edit the record in the PAML. The check is removed if you completely remove the record from the PAML.
To sort the list by "copied to PAML" or not (checked in the P column), or in order alphabetically (by source or generic medication name) or chronologically (most recent to oldest), click a heading (P, source, generic, or date).
To shorten the list by hiding details, click Collapse All (ALT+S); click Expand All (ALT+E) to display details for all records.
To generate a paper copy, click Print MSL (ALT+L).
To hide details for a single item in the list, click the medication name. Click medication name to show details.
Click to access Knowledge Link. Click to close the Knowledge Link window.
Drug Classification FAQ

If you obtain consent to access Surescripts© data after the PAML has been started, open the PAML builder, then click the patient consent link in the note below the Meds from Electronic Sources title to reopen the consent prompt. Click EMR + fill data to document consent and include any available Surescripts© data in the medication source list.

Click Rx History/CMLV to display the Consolidated Medication List Viewer (CMLV). By default, the CMLV launched from the PAML shows information from the Surescripts© network, with data from both insurance claims and participating pharmacy records of medication prescriptions filled. You must have and attest to the patient's consent to check this history. You can also set the CMLV to show medications from the other PAML sources, OnCall, LMR, MGH discharge, and BWH discharge. See Viewing Medications in the CMLV.

Click View Notes (ALT+I).
For patients with more than a few notes, scroll the upper section of the notes display to view more.
Click the link in the second column of the top section to display the contents of a note in the bottom section.
To display the note as it would appear on paper, click Print Preview. Click to generate a paper copy of the display. Click to close the preview window.
To generate a paper copy of the selected note, click Print.
To copy the entire note for pasting into other files, click Copy.
Click to access Knowledge Link. Click to close the Knowledge Link window.
Click Hide Notes (ALT+I) to close.

If it is not possible to create a PAML, click to select an option—Unable to obtain medication history, or Patient is not taking any medications
Add meds to the PAML from source list

Click the med detail line in the source list. You can add more than one med at a time from the source list by holding down CTRL while clicking the items.
Click Add (ALT+D) to take all selected records as listed. For one medication at a time only, click Modify & Add (ALT+Y) to change details if needed. See Changing records in the PAML below for further instructions.

If one of the records you select does not reference the Partners medication dictionary, you will be required to add it separately using the medication form. This process does reference the dictionary, which is needed for writing inpatient and discharge orders from PAML records.

Add meds not on the source list

Click Add med (ALT+A).
Type at least the first 3 letters of the medication name, then click Search or press ENTER.
See Changing records in the PAML below for further instructions.

Search for medication by description:

Click Add med (ALT+A).
Click Image Lookup.
Select from each list to describe the med: Color, Shape, and Score Pattern.
If there is an imprint on one or both sides, type the characters in the Side 1 and/or Side 2 fields.
Click Find Images. Results include thumbnail images with the medication name and strength.
To display an enlarged image, click a thumbnail and hold the mouse button down. Release the mouse button to close the enlargement.
Click Select this Item to return this result to the med lookup form.
See Changing records in the PAML below for further instructions.

Click to access Knowledge Link. Click to close the Knowledge Link window.

To modify an medication already on the PAML:

Click its line in the list, then click Modify (ALT+M)
If needed, double-click to select a medication with route from the first drop-down list. If you select the wrong item, click the drop-down arrow to reopen the list. If the result you want is not listed, and you do not believe that searching with different criteria will resolve the problem, click Take as Typed.
If needed, select a dose and/or frequency. Options for each include Unknown or free text. If you start typing the entry, the list scrolls automatically to the first matching item. Type to complete a free text entry for both the dose and units, and/or the frequency.
For administration as needed, click the PRN checkbox. Type a reason if applicable.
Type instructions for clinicians as needed.
If known, type the date and time the patient had the last dose.
Click Accept (ALT+T)

Click to access Knowledge Link. Click to close the Knowledge Link window.
To delete an medication record from the PAML, click its line in the list, then click Remove (ALT+R).

Medication information—Click to access Knowledge Link.
Display all PAML columns—On opening, not all columns on the PAML are displayed, to allow space for the medication source list (MSL). Click Show hidden PAML columns to display the Need to Clarify and Date columns. Click Show MSL/Collapse PAML to display the med source list again.
Sorting—The PAML on opening is sorted alphabetically A to Z by the generic name of the medication. Click the link in the column heading to sort by the entries for medication taken at, medication details, planned action on admission (all in the order defined by their drop-down option lists); need to clarify (checked, then unchecked); or date (most recent first) added. The sort marker 6 indicates which column is used.
Planned action on admission—Required for final sign off:

To select more than one record for updating at a time, press Ctrl and click each record.
Click in the Planned Action on Admission column. For multiple selected records, click for any one. The list displays just below the applicable record.
Select an option from the drop-down list.

Options highlighted in pink are checked for all of the selected records; those highlighted in beige are checked for some but not all of the selected records. For previously updated records, and asterisk (*) denotes the option selected for the record above the drop-down list, determined by which you clicked.

Click OK.

Medication Details—As needed, indicate the status of the medication at admission.

To select more than one record for updating at a time, press Ctrl and click each record.
Click in the Medication Details column. For multiple selected records, click for any one. The list displays just below the applicable record.
Click to select Patient not taking or Held before admission if applicable.
Click Preoperative instructions to display a list of common pre-op instructions. Click one or more checkboxes to select the options. For the options to hold for a defined number of days or weeks, type the number in the field provided.
Type in the text field to add comments to the selection, or as a stand-alone description.

Click OK.

Need to Clarify—If there are questions about the medication, click Need to Clarify. This is checked automatically if the dose, dose units, or frequency are not defined. Click to uncheck this indicator when the question is resolved.
Date—Date added to or updated in the PAML, recorded automatically when the record is first displayed and updated when changes are made. Click to display the audit history for the record. Click Print to generate a paper copy; click Ok to close the display.
PAML Comment—Click Add Comment or Edit Comment. Type comments, then click OK. The PAML comment can be reviewed from discharge orders. Each comment is signed and date stamped when the PAML is signed. You can add to the comments; signed comments cannot be edited.

See Overview of the MSL to PAML Comparison for a description.

Click Compare MSL to PAML <<>> to display the medication source list and the PAML side-by-side with matching records aligned.
Click the link in the column heading to sort (sort marker 6 indicates which column is used).

Date, most recent first, in MSL
Generic medication name, alphabetical, in MSL or PAML
Class, then generic name within the class, alphabetical, in MSL or PAML
Medication taken at, medication details, planned action on admission, all in the order defined by their drop-down option lists, in PAML

The matched MSL=PAML records are always aligned, regardless of the sort order.

Click in the row to add a record from the MSL to the PAML.
Click in the row to open the record in the medication form. See Changing records in the PAML below for further instructions.
Click Add med to open the medication form and look up a medication:

Lookup by name: Type at least the first 3 letters of the medication name, then click Search or press ENTER.
Search for medication by description:

Click Image Lookup.
Select from each list to describe the med: Color, Shape, and Score Pattern.
If there is an imprint on one or both sides, type the characters in the Side 1 and/or Side 2 fields.
Click Find Images. Results include thumbnail images with the medication name and strength.
To display an enlarged image, click a thumbnail and hold the mouse button down. Release the mouse button to close the enlargement.
Click Select this Item to return this result to the med lookup form.

To change the parameters of a record, click to select the record in the PAML, then click Modify to open the record in the medication form. See Changing records in the PAML for further instructions.
To delete a record, click to select the record in the PAML, then click Remove.
To generate a paper copy of the comparison as displayed, click Print.
To return to the PAML builder, click Close.

Click Sign (ALT+S).
If complete, click to check PAML Creation: Complete.

All meds in the list must have a planned action on admission for the list to be signed as complete. See Updating the list, above.

Type your signing key.
To notify the other clinicians of the status and any changes, click Pager to access online paging .

T he PPD (Partners paging directory) opens automatically when you close the signing form. Look up the recipient. The text of the page is pre-filled with your name, the patient's medical record number and name, and the date and time, noting a change to the patient's PAML.

You can edit the message as needed before sending a page .

Click Sign & exit to close PAML Builder; click Sign & Print to generate a paper copy after saving; click Sign & continue to save your work. Only Sign & exit closes the builder.

If you update the PAML, you must sign to save the edits before you can print the list.

To generate a paper copy of the list, click Print (ALT+P). The list must be signed to print; you can sign and print in one step if needed. See above, Saving the list, or below, Signing as Confirmed.
To copy to the electronic clipboard for pasting into other files, click Copy (ALT+C). The list must be signed to copy. See above, Saving the list, or below, Signing as Confirmed.
For more information on any medication in the source list or the PAML, click to access Knowledge Link. Click to close the Knowledge Link window.
To provide feedback on PAML functions to Partners Information Systems, click Feedback (ALT+F). Type your message, then click Submit. Click Clear before submitting to erase the message.

Inpatient medication orders—Select the patient from the UCM. Click Write (ALT+W), then Medications (ALT+M).
Post-Op surgeon's orders—Select the patient from the UCM. Click Post-Op Surgeon (ALT+P). Right-click the list, or click Additional Orders (ALT+A), then click Medications (ALT+M).
Post-Op anesthesiology orders—Select the patient from the UCM. Click Post-Op Anesthesia (ALT+I). Right-click the list, or click Additional Orders (ALT+A), then click Medications (ALT+M).
Discharge medication orders—Select the patient from the UCM. Click Face Sheet Discharge (ALT+F), then click the Medications folder in the Face Sheet/Discharge section.
To display the pre-admission medications list (PAML), click +PAML MEDS+ on the right side of the medication orders list. The PAML button is active if the list is in progress, ready for second review, or reviewed.
To display details of a PAML medication record in the summary area beneath the lists, click its line. To view details in a larger area, click Zoom (ALT+Z). Click Close (ALT+C) to return to the list.
PAML records are not medication orders. See Ordering an admission medication from the PAML and Ordering a discharge medication from the PAML for instructions.
To hide the PAML, click +PAML MEDS+.

Click Sign (ALT+S).
Click to check PAML Confirmed (Nurse).

All meds in the list must have a planned action on admission for the list to be signed off as confirmed. See Updating the list, above.

Type your signing key.
To notify the responding physician, click Pager to access online paging .

You can edit the message as needed before sending a page .

Click Sign & exit to close PAML Builder; click Sign & Print to generate a paper copy after saving; click Sign & continue to save your work. Only Sign & exit closes the builder.

If you update the PAML, you must sign to save the edits before you can print the list.

Click Sign (ALT+S).
Click PAML Reconciled with Admission Orders (Pharmacy) or PAML Reconciled with Transfer Orders (Pharmacy) as applicable.

All meds in the list must have a planned action on admission for the list to be signed off as confirmed. See Updating the list, above.

Type your signing key.
To notify the responding physician, click Pager to access online paging .

You can edit the message as needed before sending a page .

Click Sign & exit to close PAML Builder; click Sign & Print to generate a paper copy after saving; click Sign & continue to save your work. Only Sign & exit closes the builder.

If you update the PAML, you must sign to save the edits before you can print the list.

The PAML Reconciled with Discharge Orders checkbox in the PAML builder sign dialog cannot be edited in the builder. The box is automatically checked when the reconciliation is completed in the patient's discharge orders.

For well newborns, see Writing Nursery Discharge Orders; for all other patients, including maternity, see Reconciling the PAML and discharge medications.

The PAML Verified with Discharge Orders checkbox in the PAML builder sign dialog cannot be edited in the builder. The box is automatically checked when the verification is completed in the patient's discharge medication instructions. See Verifying the patient's pre-admission medications against the meds ordered at discharge.

After the PAML is signed, the notation above the list of "Not Signed" changes to "Last signed by" with the name, date, and time of the most recent signature. Clicking the underlined text displays the PAML history.

The history has two sections:

At the top, there is a line item for each record created, and each change made to a record after it was created. The medication name, signature, date, and time are listed with each item. The list is sorted in reverse chronological order (newest to oldest) by default. To sort by med name or user (the name of the clinician who signed), click the column heading. Scroll if the list is longer than the display area.
At the bottom, each change to the state of the PAML and the status of medication reconciliation is listed. The PAML can be In Progress, PAML Creation: Complete, or PAML Creation: Modified after Completion. (On the PAML itself, the current state is displayed in red text above the column headings for the list.) Once the PAML is complete, the medication reconciliation can be Confirmed (by nursing), Reconciled with Admission Orders (Pharmacy), Reconciled with Discharge Orders (MD, NP, PA, or CNM), and Verified with Discharge Orders (Nursing). (See next for displaying the medication reconciliation status on the PAML.) The list is sorted in reverse chronological order (newest to oldest) by default. To sort by the name of the clinician who signed, click the User column heading. Scroll if the list is longer than the display area.

Click Close to exit the display.

The PAML can be In Progress, PAML Creation: Complete, or PAML Creation: Modified after Completion. The current state is displayed in red text above the column headings for the list.

Once the PAML is complete, the processes for medication reconciliation can be signed off. Click Reconciliation Status to display a list of the processes that have been signed off. These include:

Confirmed (by nursing)—in the PAML builder
Reconciled with Admission Orders (Pharmacy)—in the PAML builder
Reconciled with Transfer Orders (Pharmacy)—in the PAML builder
Reconciled with Discharge Orders (MD, NP, PA, or CNM)— in Provider Order Entry
Verified with Discharge Orders (Nursing)— in Provider Order Entry

The Reconciliation Status button appears only If any of the reconciliation is signed off. It is located beneath the Last Signed by link.

Click Hide Reconciliation Status to save space for the PAML to display.

Build the Pre-Admission Medications List (PAML)