across the entire row. Where matching orders differ—dose, frequency, and/or PRN status (yes or no, not reason)—the inpatient record has a green background 
, the pre-admission a blue background 
in the applicable column.
For a brief description of colors, status flags, buttons, and links, see Legend for Med Reconciliation at Discharge.
Medication reconciliation at discharge—As part of discharge orders, all of the pre-admission medications, current inpatient medications, and medications for discharge must be reconciled. All three groups of orders are displayed on the discharge medications page. Pre-admission medications are drawn from the pre-admission medications list (PAML), and inpatient medications from the active medication orders in Provider Order Entry (POE). For every pre-admission and inpatient order listed, a provider must indicate whether the order is to be included in the discharge medication orders.
Medication orders for discharge—Orders on the pre-admission and/or inpatient medications list that are selected for inclusion are automatically listed as a discharge orders. Providers can also write new orders for discharge medications.
Sorting and matching—Two views, side-by-side and vertical, are available for ease of comparison of pre-admission and inpatient orders. On the comparison views, medications are sorted by top-level drug class (such as cardiovascular or respiratory); then alphabetically within the class. The classes are separated by horizontal bold lines. Orders are compared and aligned so that medications that match are either side-by-side or one after another (depending on the view). Orders are matched by the Partners Enterprise Medication Decision Support Services (EMEDS) based on criteria from First DataBank (FDB).
Criteria for matching—Two medications on two different lists (pre-admission and inpatient) are considered a match if the ingredient, route, and form are the same. If a medication on one list matches two or more medications on the other, the PRN status (yes or no, not reason), route, frequency, and dose are compared, in that order.
Free-text medications—When you write medication orders for discharge, you will be prompted to compare the discharge order with all of the free-text PAML medications. This includes discharge medications continued from the current inpatient orders as well as new medications added for discharge. Note that if a medication for inpatient treatment is entered as free-text, you should check the PAML to determine if the order also exists there. PAML records can be drawn from outpatient formularies, which do include medications that are not available from the inpatient formulary. This failure to match can result in conflicting instructions on the patient's discharge medication list (PDML), which would say "take" the free-text inpatient medication and "stop taking" the identical PAML medication. See Overview of the PDML.
Data—In the pre-admission and the inpatient lists, the medication name, dose, frequency, route, and PRN status (yes or no, not reason), and provider instructions are included. Each piece of information is listed in a separate column. The medication name is displayed with bold text until the decision whether to include in the discharge orders is selected. For inpatient and discharge medications, holding the mouse pointer over the medication name displays the entire summary of the order. Holding the mouse pointer over underlined text displays details when available; for example, instruction text (over <I>) or the PRN reason (over <R>).
Highlighting differences—Two medications on two different lists (pre-admission and inpatient), are considered identical if the medication name, dose, frequency, route, and PRN status (yes or no, not reason) are exactly the same. When there are differences between the same data for matching medications, the background is shaded to match the color of the source: pre-admission (green) or inpatient (blue). For example, a medication the patient was taking before admission, that has been continued at a different dose or frequency through the inpatient visit, has a dose/frequency with a green background in the pre-admission list, and a blue background in the inpatient list.
Reconciling—The provider writing discharge orders reconciles each pre-admission and inpatient medication order by checking either Yes or No to indicate whether the medication will be included as a discharge order. Each order with Yes or No checked is tallied and displayed at the top of the lists, along with the number of orders needing reconciliation. When Yes is checked, the medication order is added automatically to the discharge medications list. The discharge order carries over the data from the selected record. If the order is incomplete, the medication order form is invoked automatically, pre-filled with available data, awaiting completion by the ordering provider.
Side-by-side view—In the side-by-side comparison view, pre-admission and current inpatient medications are displayed next to each other, in separate lists. Each list has a pair of columns of Yes/No checkboxes. Two medications on two different lists (PAML and inpatient) are horizontally aligned if the ingredient, route, and form are the same. Orders with the same medication name, dose, frequency, route, and PRN status (yes or no, not reason) are displayed with a yellow background across the entire row. Where matching orders differ—dose, frequency, and/or PRN status (yes or no, not reason)—the inpatient record has a green background , the pre-admission a blue background in the applicable column.
Vertical view—In the vertical view, there is a singe list of orders. Matching medications that are not identical are paired with the pre-admission version above and the inpatient version beneath. Each entry has its own pair of Yes/No checkboxes. Like the side-by-side view, where matching orders differ—dose, frequency, and/or PRN status (yes or no, not reason)— the inpatient record has a green background , the pre-admission a blue background in the applicable column.
Medications with limited dosing duration—Several alerts are in place to facilitate ordering medications with taper dosing or limited doses that must be continued from the inpatient visit to the discharge setting. The ability to start discharge orders before the patient is ready to go does create the likelihood that the discharge order will go "out-of-synch" with the actual administration of the medication. Providers (MD, NP, PA, CNM) reconciling medication orders at discharge are notified for the following circumstances:
On selecting Yes to continue a taper or duration order through discharge, an alert that the selected order has limited dose duration(s), with the option to continue or edit the order for discharge
On opening discharge orders, when the eMAR (electronic medication administration record) determines that doses have been given since the discharge order was continued from the inpatient order, the option to edit the discharge medication order, or to update the discharge order to account for the doses given in-house since the order was written for discharge
On opening discharge orders, when the eMAR determines that ALL doses have been given since the discharge order was continued from the inpatient order, the option to edit the discharge medication order, or to remove it from the discharge order
On opening discharge orders, when the eMAR determines that it is not possible to calculate what (if any) doses have been given since the discharge order was continued from the inpatient order, the option to edit the discharge medication order
Orders in the discharge medications list—The dose, frequency, PRN status and reasons, and instructions of each order in the discharge meds list can all be edited by clicking the applicable column for the order and selecting from a list or typing. Orders can also be selected and edited using the full medication order form as needed. If a discharge order included from the pre-admission or inpatient list differs from the source by dose, frequency, or PRN status (yes or no, not reason), the difference is highlighted with a pink background 
.
Reviewing the discharge medications list—A view-only list of discharge orders is presented automatically when all of the medications in both the current pre-admission list (PAML) and inpatient orders have been reconciled. The pre-admission medications that were not resumed for discharge are listed at the top. These are the medications that the patient is instructed to stop taking. You can call up this review list at any time. See Reviewing Discharge Medications.
For instructions, see: