Provider Discharge Note: Against Medical Advice (AMA)
This patient is leaving against medical advice (AMA) after admission for encephalopathy, now alert and oriented with demonstrated decision-making capacity; comprehensive discharge communication with verification of understanding is essential to minimize post-discharge risks 1.
Discharge Note Template
DISCHARGE STATUS: Against Medical Advice (AMA)
ADMISSION DIAGNOSIS: Encephalopathy
DISCHARGE CONDITION:
- Alert and oriented x3
- Vital signs stable
- Decision-making capacity confirmed and documented
CLINICAL COURSE: Patient admitted with encephalopathy. Mental status improved to baseline. Patient demonstrates understanding of risks of leaving and has capacity to make this decision. Extensive discussion held regarding:
- Incomplete evaluation/treatment
- Risk of symptom recurrence
- Potential for serious complications
- Need for follow-up care
PATIENT COMPREHENSION VERIFIED: Patient able to verbalize understanding of:
- Reason for admission
- Current medical status
- Risks of leaving AMA
- Warning signs requiring immediate return
- Follow-up plan
DISCHARGE INSTRUCTIONS PROVIDED (verbal + written):
- Return precautions: confusion, altered mental status, inability to care for self, new neurological symptoms
- Medications: [list with dosing, indication, and specific instructions]
- Follow-up appointments: [specific dates/times arranged]
- Home health services: [specify services arranged]
MEDICATIONS RECONCILED: Complete list provided with clear dosing instructions 1.
FOLLOW-UP ARRANGED:
- Primary care: [date/time]
- Specialty care: [if applicable]
- Home health: [services specified]
DOCUMENTATION:
- AMA form signed by patient
- Risks explained and documented
- Patient verbalized understanding of discharge plan 1
Key Documentation Elements
The three critical tasks completed 1:
- Communicated crucial information clearly in plain language
- Verified comprehension through teach-back method (patient restated key points)
- Tailored teaching to address specific areas of confusion
Common Pitfall to Avoid: Do not simply hand forms and prescriptions without bidirectional communication—this leaves patients at risk for medication errors and failure to recognize warning signs 1.
Structured content included 1:
- Diagnosis in clear terms
- Medication changes with rationale
- Specific return precautions
- Concrete follow-up plan with appointments made
- Contact information for questions
For patients with limited health literacy or language barriers: Use teach-back method, pictograms if available, and ensure interpreter services were used if needed 1.