What must be documented when a patient leaves Against Medical Advice (AMA) after being counseled on the risks?

Documentation Requirements for Against Medical Advice (AMA) Discharge

When a patient leaves against medical advice after counseling, you must document eight essential medicolegal components, with particular emphasis on capacity assessment, specific risks discussed, patient understanding, and follow-up arrangements.

Core Documentation Elements

1. Assessment of Decision-Making Capacity

• Document explicitly that the patient has capacity to make medical decisions 1, 2, 3
• Only 22% of AMA discharges properly document capacity assessment, representing a critical gap in medicolegal protection 3
• This is your first line of legal protection—without documented capacity, the entire AMA process may be invalid 2

2. Current Medical Condition and Evaluation Status

• Document the patient's presenting signs and symptoms 3
• Record the extent and limitations of the evaluation performed to date 3
• Note any incomplete diagnostic workup or pending test results 2

3. Risks of Leaving

• Document specific risks of leaving with the current untreated or incompletely treated condition 1, 2, 3
• Include both immediate risks (e.g., bleeding, deterioration) and longer-term consequences 1, 2
• For specific conditions like thrombocytopenia, document risks such as spontaneous bleeding and intracranial hemorrhage 1
• The risks must be material and patient-specific, not generic warnings 4

4. Benefits of Staying and Proposed Treatment Plan

• Document the current treatment plan, including its risks and benefits 3
• Explain what would be done if the patient remained and the expected outcomes 2, 3

5. Alternative Treatment Options

• Document alternatives to the suggested treatment, including outpatient management options 3
• This demonstrates you explored harm reduction approaches rather than an "all or nothing" stance 5, 6

6. Patient's Explicit Statement and Understanding

• Record the patient's verbalized understanding of the risks discussed 1, 2
• Document the patient's explicit statement that they wish to leave AMA despite understanding these risks 3
• Note what specifically the patient is refusing (e.g., admission, specific procedure, further evaluation) 3

7. Follow-Up Care Plan

• Provide and document discharge instructions, prescriptions, and urgent follow-up appointments 1, 6, 3
• Schedule specific follow-up within an appropriate timeframe for the condition 1
• Give contact numbers for questions or if the patient changes their mind 4, 6
• Emphasize that the patient can return at any time for additional care 6

8. Signed AMA Form

• Obtain the patient's signature on an AMA discharge form when possible 2
• If the patient refuses to sign, document this refusal 2

Critical Legal Protections

A properly executed AMA discharge provides two key legal protections:

• Proof that your duty to the patient ended with their informed decision to leave 2
• Evidence that the patient assumed the risk of subsequent complications 2

Common Pitfalls to Avoid

The "You Leave With Nothing" Myth

• Never perpetuate the concept that AMA means the patient receives no care 6
• Patients leaving AMA should still receive medications, prescriptions, discharge instructions, and follow-up arrangements 1, 6
• This harm reduction approach is both ethically appropriate and legally protective 5, 6

Inadequate Documentation

• Only 4.1% of AMA discharges meet minimal EMTALA standards in documented cases 3
• No single chart in one study fulfilled all eight medicolegal standards 3
• Your documentation is your only legal protection—verbal counseling alone is insufficient 2, 3

Missing Capacity Assessment

• Capacity documentation is absent in 78% of AMA cases despite being legally essential 3
• Without documented capacity, the patient's decision may be considered invalid 2

Quality Measure Implications

Document that the patient was informed they will be excluded from quality measure denominator populations due to AMA status 4, 1

• This applies to performance measures for conditions like myocardial infarction, heart failure, and other quality metrics 4
• While this may seem administrative, it demonstrates thoroughness in your counseling 1