Discharge Against Medical Advice (AMA) Note

(Use neutral, patient-centered language. Do not infer or fabricate information. Omit non-applicable sections based on event classification. If information is missing, explicitly state why.)

Date/Time of AMA Decision: [timestamp] Time of Departure: [timestamp if different]
Author: [name/role] Attending: [if different]
Location: [ED/unit/service]
Interpreter: [name/ID and type] (Only include if used)
Support Person Present: [name and relationship] (Only include if involved in discussion)

Event Classification

Type of departure: [AMA after clinician discussion / Refusal of specific intervention while remaining in care / Elopement / Left Without Being Seen (LWBS) / Refusal of recommended admission or transfer]

[One-sentence narrative context] (Briefly state circumstances. Do not classify as "AMA after discussion" unless a substantive discussion occurred.)

Clinical Snapshot

• [Chief concern or working diagnosis]
• [Key abnormal findings and clinical severity]
• [Pertinent comorbidities affecting risk]
• [Last vital signs and mental status near departure]
• [Essential test results relevant to risk discussion]
• [What remains incomplete or pending] (If unable to reassess before departure, state why.)

Decision-Making Capacity Assessment

(Required for AMA after discussion, refusal of high-risk interventions, or when capacity concerns exist. If patient departed before assessment, document what was and was not assessed and why. Do not rely solely on orientation; document functional elements.)

Decision being assessed: [specific decision, e.g., "declining admission," "refusing CT scan"]

Barriers or risk factors: [factors impacting capacity or communication] (e.g., intoxication, sedation, language barriers, acute distress; include mitigation steps taken.)

• 1) Communicate a stable choice: [findings on ability to express a consistent choice] [brief quote if helpful]
• 2) Understand information: [understanding of diagnosis, uncertainty, recommended plan, benefits/risks] [brief quote]
• 3) Appreciate personal relevance: [ability to relate condition and consequences to self] [brief quote]
• 4) Reason about options: [rationale comparing options, acknowledging uncertainties] [brief quote]

Capacity conclusion: [Patient has decision-making capacity for this decision / Patient lacks decision-making capacity for this decision] (If lacks capacity, document surrogate involvement, emergent exception, or protective steps taken.)

(If unable to complete: "Unable to complete capacity assessment—[reason]")

Informed Refusal Discussion

(Required for AMA after discussion and refusal of significant interventions. For elopement/LWBS, document that informed refusal could not be completed and why.)

Recommended care and rationale: [what was advised and clinical reasoning]

Benefits of recommended care: [expected outcomes; acknowledge uncertainty as applicable]

Risks of refusing/leaving: [condition-specific risks including serious outcomes when clinically plausible]

Alternatives offered: [e.g., partial workup, observation, oral vs IV therapy, outpatient follow-up, transfer, involvement of supports]

Questions and responses: [opportunity provided and patient engagement]

Evidence of understanding (teach-back): [patient paraphrase or quote demonstrating understanding]

Explicit refusal: [tests/treatments/admission/transfer refused] [what patient requested instead, if anything]

Discussion language: [English / patient's preferred language via interpreter] (Document interpreter name/ID if used.)

(If not completed: "Informed refusal discussion could not be completed—[reason]")

Patient's Stated Reasons and Barriers Addressed

Patient's stated reason(s) for leaving: [direct quotes when possible] (If declined to state, document "Patient declined to provide reasons.")

• Identified barriers: [practical barriers: work, childcare, transport, cost, fear, dissatisfaction, withdrawal symptoms, mistrust, etc.]
• Actions taken to address barriers: [analgesia, social work consult, timeline clarification, family contact, transport arrangement, financial counseling, etc.]

Harm-Reduction Discharge Plan

(Required whenever patient departs, regardless of pathway.)

• Care accepted before leaving: [medications administered, procedures completed, wound care, naloxone, supplies provided, etc.]
• Prescriptions provided: [medications with dosing] (Note if dispensed on site. If refused, document offer and refusal.)
• Follow-up plan: [specific appointment with date/time/location if scheduled; otherwise recommended timeframe and clinic type]
• Return precautions: [condition-specific warning signs requiring immediate return] (Include explicit invitation to return at any time.)
• Pending results and contact plan: [pending labs/imaging/cultures], [who will review], [how patient will be contacted], [verified contact information]
• Departure logistics: [IV/lines removed], [belongings returned], [mode of departure] (If impaired, document safe transport counseling and efforts.)

(For elopement: document time last seen, charge nurse/security notification per policy, attempts to locate/contact patient, and that discharge instructions could not be provided.)

Notifications

• PCP: [notified / attempted / unable to reach] [details]
• Primary team: [notified / not applicable] (If covering clinician authored note.)
• Consultant: [service notified] (If pending recommendations.)
• Family/support person: [notified with patient permission / patient declined permission / unable to reach]

Refusal Documentation

AMA/Refusal form: [offered and signed / offered but patient refused to sign / not offered—document reason]

Witness: [name/role] (If patient refused signature or per institutional policy.)

(Written refusal supports but does not replace the substantive documentation above. Do not escalate coercively for signature.)