Overview of the PAML Builder

 

Opening the Builder—You can access the PAML Builder at any time by selecting a patient and clicking the Pre-Admit Med List button on the Unit Census Monitor (UCM). The PAML Builder is accessible for all inpatients, including those with orders on paper who do not have electronic orders in Order Entry.

PAML Alerts—On writing the first orders for a patient who does not have a PAML completed, MDs, NPs, CNMs, and PAs are prompted to create the list. This prompt appears every four (4) hours after the admission, whenever an MD, NP, CNM, or PA clicks Write, View>Write, Post-Op Surgeon, or Post-Op Anesthesia, until the PAML is signed as creation complete. You have the option to defer work on the PAML for the first 18 hours after the patient is admitted. This prompt does not apply to neonates (patients younger than 28 days).

PAML at 18 Hours Post-Admission—If a patient's PAML has not been completed within 18 hours of admission, MDs, NPs, CNMs, and PAs are prompted to complete the list. This prompt appears every time an MD, NP, CNM, or PA clicks Write, View>Write, Post-Op Surgeon, or Post-Op Anesthesia, until the PAML is signed as creation complete. This prompt does not apply to neonates (patients younger than 28 days).  As with the prompt presented earlier, the clinician has the option to defer, but must indicate that he or she is either entering emergency orders or serving as a consultant for the care team. Any time a clinician defers for these reasons, the information is recorded for compliance reporting.

PAML In Progress—If you opt to create the list when prompted, its status is set to In Progress. The patient's order status of <PAML> indicates that the process has been started.

Allergy and AMS Information—Medication allergies are displayed on the PAML. Note that the PAML Builder does not perform intervention checking for allergies or drug-drug interactions. These checks are performed when you write orders for both the inpatient visit and for discharge. displays in the identification section for patients who are active with Anticoagulation Management Services. Clicking the icon displays 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.)

The Electronic Medication Source List (MSL)—The PAML builder offers as a starting point any applicable drug orders in Partners electronic records, including the LMR (Longitudinal Medical Record) active medication list, OnCall active medications, and discharge medication orders from the most recent past admission to MGH and BWH. See Working with the Electronic Source List. You can print the medication source list to review with the patient and family. See Printing the List of Meds from Electronic Sources.

Allergy Manager—View active and inactive allergies and reactions that have recorded for the patient in the PEAR. Authorized users can add, edit, and confirm allergy information. This functionality is not available for users with view-only access. See Managing Allergies.

Rx History—The patient's medication prescription history from the Surescripts© network is available from the PAML builder. See Viewing the Patient's Medication Prescription History.

MSL to PAML Comparison—The MSL to PAML comparison provides a side-by-side display of the records in the electronic medication source list (MSL) and those in the current pre-admission medications list (PAML). The comparison highlights differences between the two lists, and provides many of the functions of the PAML builder for updating the list. See Comparing the MSL to the PAML.

"Empty" PAML—You have the option to leave the PAML empty if the patient is not taking anything, or if you cannot obtain accurate information.

Adding Records to the List—You can add medications to the PAML whenever you have the information. You can select one or more meds from the electronic source list in the builder and add them to the PAML with a single click. You can also make changes to these records when you add them, including modifications of the dose, frequency, as needed administration, and instructions. You can also record the date and time of last administration when available. If needed, you can add meds to the PAML directly, and change records that were previously added to the list. See Adding and Modifying Medication Records in the PAML.

Image lookup—If you have a med in hand with no clear identification, you can search for images to match using a description of the color, shape, score pattern, and imprints. Having looked up the med, you can add it to the PAML and complete administration information as needed for the record.

Planned Action on Admission—Every record added to the PAML must have a planned action on admission (PAA) before the list can be signed as PAML Creation: Complete. The options are:

To assist in decision-making, the availability of a selected medication through the pharmacy formulary is displayed with the options for planned action on admission. See Updating the PAML.

Medication Taken at location—You can document the location(s) at which the patient received any medications before admission. Options include home, nursing home, rehabilitation, transferring hospital, unknown, and free-text entries. You can select one or more locations as applicable. This allows a distinction between various pre-admission care settings, and makes it easier to determine the need to continue, change, substitute, or hold each medication as the patient moves forward through the continuum of care of inpatient admission, transfer, and discharge. See Updating the PAML.

Medication details—You can annotate each record to provide information, such as patient failure to adhere to a treatment or treatment put on hold before the admission. You can also include reasons for modifying the record when it differs from the source list. See Updating the PAML.

Need to Clarify—If you have questions about any of the meds, you can indicate Need To Clarify so that you and any other clinicians who access the PAML are aware that the record is not confirmed. If a medication record on the PAML does not include the dose, dose units, or frequency, Need to Clarify is checked automatically. You can clear the indicator as appropriate. See Updating the PAML.

Saving, Signing, Copying, and Printing the List—Every record you add to the PAML is saved as soon as it appears on the list, whether you add it directly, or modify as you add. Records can be removed or modified as needed. Records in the PAML are not orders; the medications listed are not added to the inpatient orders. See Saving the list. You (and other clinicians) can continue to work on the list until it is complete. You can print a copy to review with the patient, family, and healthcare providers, and copy and paste the list to electronic records and documents. The list must be signed before you can print or copy it. See Printing the PAML.

PAML Creation: Complete—When the PAML is ready, and every record has a planned action on admission, MD, NP, CNM, or PA can sign it as PAML Creation: Complete. You can page the responding provider when signing the PAML. See Signing as PAML Creation: Complete.

Confirmation—The second step of medication reconciliation is the confirmation of the PAML by a second clinician, usually the RN. Nurses can update the PAML, and sign that it is confirmed, but cannot sign it as PAML Creation: Complete. The nurse should print the PAML from the builder, then go over the list with the patient or family. Having done this, the nurse can sign the PAML in the builder as confirmed. The nurse can email or page the responding provider when signing the PAML. See Confirming the PAML.

When the confirmation of the PAML is signed off, the <PAML> flag is removed from the patient's Order Status in the UCM.

Notifying Providers—You can page care providers via the Partners phone and paging directory (PPD), and/or send an email notification, from the PAML Builder. See Notifying Care Providers.

Medication Orders for the Admission—Medication orders for inpatient treatment 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.

Reconciling the PAML with Admission Orders—Pharmacy can access the PAML for reconciliation with the active inpatient medication orders when performing the Pharmacy medication review. Pharmacy can update the PAML, but cannot sign it as complete or confirmed. Having reconciled the list, pharmacy staff can sign off on the pharmacy's separate review of the PAML. Pharmacy can email or page the responding provider when signing the PAML. See Pharmacy Review and Reconciliation.

Discharge Orders (except neonates)—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:

Nursing must verify the discharge medications list with the PAML at discharge. This is documented with the medication status in the discharge instructions.

Tracking Changes to the PAML—The PAML builder provides an audit trail of both the creation of and changes to the records in the list, and the updates to the patient's medication reconciliation status. All changes are recorded in a separate line item that is stamped with the signer's name, the date, and time. The list itself may be In Progress, PAML Creation: Complete, or (if it is edited after this) PAML Creation: Modified after Completion.

Changes made to 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).

Medication Reconciliation Status—Once the list is signed off as PAML Creation: Complete (even if it is modified later), it can be confirmed. The steps to complete reconciliation include the following: