Documentation of Against Medical Advice (AMA) Discharge for Patients with Thrombocytopenia
When documenting a patient leaving against medical advice (AMA) with thrombocytopenia, you should clearly document the risks discussed, the patient's decision-making capacity, and the specific medical concerns related to their thrombocytopenia to protect both the patient's health outcomes and provide appropriate medical-legal documentation.
Essential Documentation Components
Patient Identification and Decision-Making Capacity
- Document the patient's full identification and confirm their decision-making capacity at the time of AMA discharge 1
- Note any factors that might impair judgment (substance use, mental health issues, etc.) 2
Medical Condition Documentation
- Clearly document the current platelet count, trend, and severity of thrombocytopenia 1
- Include any active bleeding or risk factors for bleeding 2
- Document any diagnostic tests that were planned but not completed due to the AMA discharge 3
Risks Specifically Discussed
- Document the specific risks of leaving with untreated/undertreated thrombocytopenia that were explained to the patient 4
- Include potential complications such as:
AMA Process Documentation
- Note that the patient was informed they are leaving "against medical advice" 5
- Document that the patient understands they are being excluded from denominator populations in quality measures due to their AMA status 5
- Record the time and date of the AMA discharge 1
Follow-up Plan
- Document specific follow-up recommendations provided to the patient 2
- Include any prescriptions given and instructions for medication use 6
- Note any arrangements made for outpatient follow-up appointments 5
Sample Documentation Template
Patient Name: [Name]
Date/Time of AMA Discharge: [Date/Time]
ASSESSMENT OF CAPACITY:
Patient demonstrates full decision-making capacity and understanding of the medical situation and risks involved with leaving AMA.
MEDICAL CONDITION:
Current platelet count: [value] (reference range: [range])
Trend: [improving/worsening/stable]
Active bleeding: [present/absent]
Planned but incomplete diagnostics: [list]
RISKS DISCUSSED:
I have specifically discussed the following risks of leaving with untreated thrombocytopenia:
1. Risk of spontaneous bleeding, particularly with platelet count below [value]
2. Potential for intracranial hemorrhage or other life-threatening bleeding
3. Possible progression of underlying condition causing thrombocytopenia: [suspected cause]
4. Increased risk of morbidity and mortality with AMA discharge
PATIENT UNDERSTANDING:
Patient verbalized understanding of these risks but still wishes to leave AMA.
FOLLOW-UP PLAN PROVIDED:
1. Urgent follow-up appointment scheduled with [provider] on [date/time]
2. Prescriptions provided for: [medications]
3. Instructions to return immediately if: [specific warning signs]
4. Laboratory follow-up recommended within [timeframe]
PROVIDER SIGNATURE: ____________________Common Pitfalls to Avoid
- Avoid using coercive language or threats in the documentation 4
- Don't fail to document the patient's decision-making capacity at the time of AMA discharge 1
- Don't omit specific risks discussed related to thrombocytopenia 2
- Avoid incomplete documentation of follow-up plans 5
- Don't forget to document that the patient was excluded from quality measures due to AMA status 5
Best Practices for Risk Mitigation
- Consider having a witness present during the AMA discussion 1
- Document any attempts to address the patient's reasons for leaving AMA 3
- Provide written discharge instructions specific to thrombocytopenia management 2
- Record any consultation with other healthcare providers regarding the AMA situation 4
- Document any efforts to arrange alternative care options that might be acceptable to the patient 6