Effect of Leaving Against Medical Advice on Medical Records
When a patient leaves against medical advice (AMA), they are systematically excluded from quality measure denominator populations across all major cardiovascular performance metrics, which means their care outcomes are not counted in hospital quality reporting or performance assessments. 1
Quality Measure Exclusion
The most significant effect on the medical record is the automatic exclusion from quality measure calculations:
Patients leaving AMA are excluded from denominator populations for all major ACC/AHA performance measures including aspirin administration, beta-blocker therapy, statin prescribing, antiplatelet therapy, and cardiac rehabilitation referral metrics 1
This exclusion applies universally across conditions including acute myocardial infarction (both STEMI and NSTEMI), coronary artery revascularization (PCI and CABG), atrial fibrillation, and heart failure 1
The AMA designation removes the patient from quality reporting regardless of whether they received appropriate care prior to leaving, meaning their outcomes do not impact institutional performance scores 1
Required Documentation Standards
The American College of Cardiology and American Heart Association emphasize that proper AMA documentation must include patient-specific risks, not generic warnings, along with evidence of the patient's understanding of these risks. 2
Essential documentation elements include:
Specific risks of leaving with the current untreated or incompletely treated condition, including both immediate and longer-term consequences tailored to the individual patient's clinical situation 2
The patient's verbalized understanding of the discussed risks, providing evidence that informed decision-making occurred 2
Discharge instructions, prescriptions, and urgent follow-up appointments to ensure continuity of care and reduce adverse outcomes 2
Contact numbers for questions or if the patient changes their mind about leaving 2
Documentation that the patient was informed they will be excluded from quality measure denominator populations due to AMA status 2
Clinical Implications of AMA Documentation
The AMA designation carries significant clinical consequences beyond quality metrics:
Patients leaving AMA have substantially higher morbidity and mortality compared to those completing treatment, with increased rates of readmission, recurrent infections, and embolic events 3, 4
Approximately 1-2% of all hospital admissions result in AMA discharge, representing a persistent healthcare system challenge 5, 4
Patients with multiple AMA discharges represent a particularly vulnerable population with high rates of psychosocial stressors (69% financial stress, 49% housing insecurity), substance use disorders, and psychiatric comorbidities 6
Readmission within 30 days occurs in over half of patients with recurrent AMA discharges, with an average of 10 hospitalizations during multi-year follow-up periods 6
Common Pitfalls to Avoid
Never use generic risk warnings when documenting AMA discharges—the documentation must reflect patient-specific risks based on their actual clinical condition and treatment plan 2
Do not simply have patients sign a form without documented discussion—evidence of the patient's understanding and the specific risks communicated is essential for both medicolegal protection and quality documentation 2
Avoid viewing AMA designation as punitive—instead, provide discharge instructions, medications, and follow-up appointments to maintain continuity of care despite the patient's decision to leave 2