All of the pre-admission medications, current inpatient medications, and medications for discharge must be reconciled as part of discharge orders. All three—pre-admission, inpatient, and discharge—are displayed on the Medications page of the Face Sheet Discharge Orders. 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.
A running count of the number of orders reconciled is displayed at the top of the lists, along with the total number of orders needing reconciliation. The Face Sheet and Discharge Orders cannot be signed as final until all of the pre-admission and inpatient medications are reconciled with the discharge meds.
The Patient Discharge Medication List (PDML) is generated from the medication reconciliation. The PDML should document the complete medication status for the transition of care from inpatient to discharge. It is not simply a list of medications (if any) prescribed as post-discharge treatment for the current admission. The PDML must also address all the medications the patient was taking before the inpatient stay. The reconciliation of the PAML allows you to inform the patient whether to continue or stop taking a pre-admission med, and whether there are changes to the dose, frequency, or other instructions for those are continued.
The Discharge Med Review displays automatically when the discharge orders are signed as final, and whenever you sign an amendment to the discharge orders. This review makes it easy to see how the PDML will appear to the patient. The top section lists pre-admission meds that the patient should stop taking. A separate section lists all of the medications the patient should be taking after discharge. You must review this, along with the PDML itself, to be sure that instructions you're sending with the patient are complete, accurate, and clear.
Features—This document is designed to be patient-friendly. Orders are organized, translated, and annotated to make it easier for the patient to understand the treatment.
Medications to be taken are listed in a section labeled "Your new medication list." If the list spans multiple pages, this heading is continued on each page as needed.
The terminology is presented in everyday English. For example, the route for PO medications is described as "by mouth" and TID frequency is listed as "three times a day."
Each medication to be started on discharge is highlighted with "This is a new medication."
Each medication to be continued or resumed with adjustments to the dose and/or frequency is highlighted: "This is a change in how much of this medication to take " and/or "This is a change in when to take this medication."
Medications that are to be taken for a limited duration are listed in a distinct section with the heading "Take these medications for the specified number of doses."
PRN Medications are listed in a distinct section with the heading "Take these medications ONLY if you need them."
Pre-admission medications that should not be resumed are listed in a distinct section with a large stop sign.
Discharge orders that have been manually reconciled with "take as typed" pre-admission medications include a note "This is the same as..."
Editing—The PDML reflects the medication reconciliation and orders on the Face Sheet/Discharge Medications list. Only MDs, NPs, and PAs can edit this list. See Ordering Medications for Discharge. The PDML is not available until all the of the pre-admission and current inpatient medications have been reconciled, and the discharge orders have been signed. RNs are not able to change the PDML; contact the ordering provider to request a change.
RN Responsibilities—As part of the medication reconciliation process, RNs review the pre-admission medication list (PAML) with the patient. Before the patient is discharged, the nurse prints the PDML and reviews it with the patient. RNs and NPs can write nursing instructions for any med on the Discharge Medications list. These instructions print on the Patient Discharge Medications List (PDML). See Writing Instructions for a Discharge Medication.
Generating a paper copy—The PDML is printed separately from the post-hospital care plan. It can be printed from the nursing discharge Medications folder, the face sheet/discharge Medications folder, and the Print folder. The PDML is saved with the discharge orders when it is printed. See Printing Discharge Orders, Forms, and Instructions.
Changes made to either the pre-admission medications list (PAML) or the 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).
Discharging the patient—Each patient who is discharged home should be given a copy of their list at the time of discharge. When the patient is ready to go home, the RN checks the discharge orders to be sure that the medications have not changed. If there are changes, the nurse prints a new copy of the PDML, and reviews the changes with the patient. The last version printed is saved in both the patient's Discharge Orders in the medical record for the visit, as well as on the Reports tab of the Clinical Data Repository (CDR). See Viewing Reports in Results.