Left Without Being Seen/Elopement Note

(Use neutral, factual language throughout. Quote patient statements directly when they communicate intent or refusal. Do not infer that risks were explained or that capacity was assessed unless explicitly documented. When key information is missing, use "Unknown" or "Not assessed" rather than omitting. Omit sections that do not apply. Do not include internal occurrence report details beyond noting one was filed.)

Date/Time: [Date and time of documentation]

Patient: [Name, MRN, age, sex] (If identity unknown, write "Unknown patient" with any temporary identifier and concise physical description.)

Location: [Waiting room / Triage bay / ED room number / Unit]

Chief Complaint: [Chief complaint from registration or triage]

Triage Level/Vitals: [Triage level and initial vitals with timestamp] (If not obtained, state "Not obtained.")

Event Classification

• Type of departure: [LWBS (left prior to provider evaluation) / Elopement (left without authorization) / Left Before Treatment Complete / Other: factual behavior description] (If uncertain, provide factual behavior description without assigning a label.)
• Stage of care at departure: [Left prior to triage / After triage but before provider evaluation / After provider contact but before workup complete / With pending results]
• Brief circumstances: [Concise factual description of events surrounding departure]

Timeline of Events

• Arrival/registration: [Date/time] (Source: [registration system / staff report / patient report / Unknown])
• Triage completed: [Date/time / Not completed]
• Last staff contact prior to departure: [Date/time, staff role, name if known]
• Provider contact: [Date/time / None]
• Patient stated intent to leave: ["Direct quote" at date/time / Not stated]
• Last seen or discovered missing: [Date/time; witnessed vs estimated; source]
• Departure time: [Witnessed date/time / Estimated date/time / Unknown]
• Elopement protocol activated: [Date/time / Not activated]

Care Offered and Completed

• Care available/offered: [Medical screening exam, monitoring, diagnostics, treatments available]
• Care completed prior to departure:
  • Triage findings: [Brief summary / Not assessed]
  • Vital signs: [Values with timestamps / Not obtained]
  • Nursing assessment: [Brief objective findings / Not assessed]
  • Tests performed: [Labs, imaging, other with results / Pending / Not performed]
  • Treatments administered: [Medications with dose/route/time, procedures / None]
  • Devices at departure: [IV, monitor, other and status / None]
  • Orders placed but not performed: [List / None]

Clinical Status at Last Assessment

• General appearance: [Brief objective description]
• Mental status: [Alert/oriented status, confusion, suspected intoxication, distress / Not assessed]
• Mobility/gait: [Observed mobility / Not observed]
• Safety concerns: [Suicidal ideation, abnormal vitals, altered mental status, other concerns / None known]

(If no assessment beyond registration occurred, state explicitly: "No assessment beyond registration occurred.")

Decision-Making Capacity and Informed Refusal

(Include this section when staff had opportunity to discuss leaving with the patient, when capacity concerns exist, or for high-risk presentations. Omit if no contact occurred prior to departure.)

• Discussion occurred: [Yes / No] (If no, document: "Patient left prior to discussion of risks; unable to assess capacity at time of departure.")
• Capacity elements observed:
  • Communicated a clear choice: [Yes / No / Unclear]
  • Understood concerns/recommendations: [Yes / No / Unclear] (Document in patient's own words if stated.)
  • Appreciated risks/benefits: [Yes / No / Unclear]
  • Reasoning coherent: [Yes / No / Unclear]
• Informed refusal counseling:
  • Recommended care: [Brief description]
  • Risks explained: [Condition-specific risks discussed] (Only include if explicitly discussed.)
  • Benefits of staying: [Brief description]
  • Alternatives offered: [Return to ED / Call 911 / Outpatient follow-up / Other]
  • Questions addressed: [Yes / No / None asked]
  • Refusal form: [Offered and signed / Offered and refused (witness: name, role) / Not offered]

Response Actions and Contact Attempts

(Required for elopement cases; include for LWBS when high-risk or when contact was attempted.)

• Overhead page: [Date/time, outcome / Not attempted]
• Department/unit search: [Areas searched, date/time, outcome / Not performed]
• Security notified: [Date/time, description provided / Not notified]
• Camera review: [Performed with findings / Not performed]
• Police notified: [Yes with reason and time / No]
• Contact attempts: [Phone/text/portal method, date/time, outcome] (If reached, summarize information provided and patient response. If voicemail, note message left without clinical details. If contact information unavailable or invalid, document this limitation.)

Return Instructions

[Safety instructions communicated including general return precautions and condition-specific red flags] (Include crisis resources such as 988/911 when psychiatric concerns exist. If results are pending, note that the ED may attempt contact and encourage the patient to remain reachable. If no instructions could be delivered, state: "Return precautions could not be reviewed; patient left prior to contact.")

Notifications

• Attending physician/ED leadership: [Name, role, date/time / Not notified]
• Charge nurse/supervisor: [Name, role, date/time / Not notified]
• Security: [Name, date/time / Not notified]
• Risk management: [Name, date/time / Not required]
• Consulting services: [Service, name, date/time / None involved]
• Occurrence report: [Filed / Not filed]

Documentation Limitations

This encounter ended prior to completion of recommended evaluation. Medical screening exam: [Performed / Not performed]. [No final diagnosis established / Preliminary impression only]. Patient's last known objective status: [Brief summary of last documented objective findings].