Overview of the PAML Builder

 

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Opening the Builder—The PAML Builder is accessible for all inpatients, and opens automatically after you open the Admit Diagnosis Template in BICS. After the PAML is created, access the PAML Builder in BICS Order Entry

PAML In Progress—If you opt to create the list, its status is set to In Progress. The patient's order status of <PAML> indicates that the process has been started. If the PAML is still In Progress after 18 hours, the next provider writing orders is prompted to edit the PAML. The prompt to edit the PAML displays again at 48 hours if the list is still In Progress then.

The Electronic Source List—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 from MGH, and discharge medication orders from the most recent past admission to BWH. You can print the medication source list to review with the patient and family. 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 complete, and every record has a planned action on admission, you can sign it as complete. The first step of medication reconciliation is complete when the admitting clinician signs the PAML as complete. This status sends a page to pharmacy to review the patient's PAML, involving another clinician in the medication reconciliation process. Without this step the review process by the pharmacist will not happen. You can email or page the responding provider when signing the PAML. See Signing the PAML as 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.

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—All medications except those flagged to hold or discontinue should have a corresponding medication order written in BICS Order Entry. Medications may be held for the entire visit, or until completion of a procedure—write the orders as appropriate to the course of care. These medication orders are NOT written automatically when the medications are recorded in the PAML. BWH Information Systems staff are actively working to create a link from PAML to BICS order entry to help the workflow of medication ordering.

Reconciling the PAML with Admission Orders—Pharmacy can access the PAML for reconciliation with the active inpatient medication orders. 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 Signing off the PAML reconciliation (Pharmacy).

Discharge Orders—An MD, NP, or PA must sign off the reconciliation of the PAML with medication orders for discharge, and a nurse must sign separately to verify. Clinicians can email or page the responding physician when signing the PAML. See Reconciling and verifying the PAML for Discharge.

Medication reconciliation must be verified at discharge. Discharge orders cannot be signed as final until both of the following are completed:

If you try to check the statement before the PAML is signed as complete, you will be prompted to do so. Clicking Yes at this prompt opens the PAML builder; clicking No unchecks the reconciliation statement. See Signing the PAML as complete, with additional information on updating the list.

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.

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

 

Questions or Concerns? Please contact Dr. Jeffrey Schnipper (#32900), jschnipper@partners.org.