On Admission (except neonates)
Physician, Nurse Practitioner, Physician Assistant, Certified Nurse Midwife—On admission, open the PAML Builder and print a list of the medications available from electronic sources. See Printing the List of Medications from Electronic Sources. If there are no electronic sources of medications, start the process using information obtained from other sources, such as the patient and family. Review the preadmission medications, herbals, and supplements with the patient, family, and/or caregiver.
Create as complete a PAML as possible in the PAML Builder. (You have the option to leave the list empty if you cannot get a medication history, or the patient has not been taking any medications prior to admission). You can save the list as a draft, and come back to update it as more information becomes available. See Building the Pre-Admission Medication List (PAML). When the PAML has been started, the patient's Order Entry status includes <PAML>.
Select a Planned Action on Admission for each of the medications in the PAML When you are reasonably certain that the list is complete, and have set the planned action for all of the meds, sign as PAML Creation: Complete. The following section for RNs describes the role of the clinician who confirms the PAML. This is not restricted to RNs; another MD, NP, PA, or CNM can also sign the PAML as confirmed.
Write an order for each pre-admission medication that you planned to continue or substitute. These medication orders are NOT written automatically when the medications are recorded in the PAML See Writing Inpatient Medication Orders From the PAML and Writing Medication Orders. Surgeons and anesthesiologists can also check the PAML when writing post-op orders—see Writing Post-Op Medication Orders From the PAML.
You can modify the PAML throughout the visit when additional medication information becomes available, reiterating the update and second review process as needed.
Registered Nurse—For patients whose Order Status includes <PAML>, open the PAML Builder and print the PAML. See Printing the Pre-Admission Medication List (PAML). Using the printed PAML as a worksheet, review the pre-admission medications with the patient, family, and/or caregiver. Identify any discrepancies, and discuss changes with the admitting MD/NP/PA.
You can update the online PAML as needed. If medication information cannot be confirmed with the patient, family and/or caregiver, make a notation in the Comment section of the PAML. See Updating the Pre-Admission Medication List (PAML).
When you are reasonably certain that the list is complete, and have set the planned action for all of the meds, sign the online PAML as the reviewer. See Signing the PAML as Confirmed. Discard the paper copy of the PAML in the recycle bin.
Pharmacy—In addition to reviewing and approving orders for medications, pharmacy staff must reconcile the planned action on admission for each of the medications on the patient's pre-admission list (PAML) with active in patient orders. Patients with unreconciled lists are flagged with PAML in the Decentralized Pharmacy Review and Approval Queue. Print the PAML to use as a worksheet for comparison (see Printing the PAML). Resolve discrepancies between the PAML and the admission medication orders with the appropriate MD/NP/PA. You can update the PAML as appropriate. Once the admission medication orders have been reconciled with the PAML, sign off in the Decentralized Pharmacy Queue. See Pharmacy Reconciliation of Medications at Admission and Transfer.
On Transfer (except neonates)
Physician, Nurse Practitioner, Physician Assistant, Certified Nurse Midwife—At the time of transfer between services or levels of care within the hospital, compare the PAML with the active transfer medication orders. If needed, update orders in POE, as appropriate for the new level of care.
Registered Nurse—On activating transfer orders, review the medications for consistency with the PAML.
Pharmacy—Compare the activated transfer medications orders with the PAML.
On Discharge (except neonates)
Physician, Nurse Practitioner, Physician Assistant, Certified Nurse Midwife—At hospital discharge, compare the active medications in POE with the PAML in the Discharge Medications page of the Face Sheet Discharge module and order the discharge medications. Incorporate the final discharge medication list and the PAML into the discharge summary that accompanies the patient.
Medication reconciliation must be verified at discharge. Discharge orders cannot be signed as final (that is, "the patient is ready to go") until both of the following are completed:
The PAML is signed as ready for review
As of January, 2010, each medication on the PAML and each active inpatient medication is reconciled using the Discharge medication comparison list. See Reconciling Medications at Discharge for more information, demonstrations, and procedures.
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. Prescriptions for chemotherapy cannot be generated using the discharge orders function. Contact the patient's oncologist if needed.
Registered Nurse—Compare the discharge medications with the PAML, and notify the MD/NP/PA of any unexplained differences. The MD/NP/PA can adjust the discharge medications or PAML, as appropriate. Click the "Check here if pre-admission med list has been verified with discharge meds" checkbox in the Nursing Discharge Medications section. See Verifying the patient's pre-admission medications against the meds ordered at discharge. This indicates that the PAML and discharge medications have been verified by a nurse. Review the discharge medications with the patient, family, and/or caregiver, and give them a copy of the completed discharge medications which are located on the Post-Hospital Care Plan. Note: the PAML is incorporated into the Patient Care Referral form. In order to prevent confusion, the patient should NOT be given a copy of the PAML.