Discharge Against Medical Advice Documentation Audit

Audit template for reviewing AMA discharge documentation, including capacity assessment, risk explanation, and patient acknowledgment.

Audit Details

• Encounter date and record reviewed are identified
  Document the date of the encounter and the chart or record identifier reviewed.
• Discharge type documented as against medical advice or equivalent
  Verify the record clearly indicates the patient left AMA, refused recommended care, or an equivalent documented disposition.
• Reviewer name and role documented
  Enter the auditor's name, title, or role.
• Setting identified
  Select the care setting where the AMA discharge occurred.

Capacity Assessment

• Decision-making capacity assessed and documented
  Verify the note includes an assessment of the patient's ability to understand, appreciate, reason about, and communicate a choice regarding leaving.
• Mental status or factors affecting capacity addressed
  Check whether intoxication, delirium, pain, psychiatric symptoms, language barriers, or other factors affecting capacity were considered.
• Capacity assessment includes rationale
  Capture the specific clinical rationale supporting the capacity determination.
• Interpreter or communication support documented when needed
  Verify interpreter services, assistive communication, or other support was documented when language or communication barriers existed.
• Capacity concerns escalated when indicated
  Confirm the chart shows escalation to the attending clinician, psychiatry, ethics, or another appropriate resource when capacity was unclear or impaired.

Risk Explanation and Informed Refusal

• Reason for recommended continued treatment documented
  Document the diagnosis, concern, or treatment recommendation the patient declined.
• Material risks of leaving were explained
  Verify the record states the patient was informed of material risks, including worsening condition, disability, complications, or death when applicable.
• Benefits of staying or completing treatment were explained
  Confirm the chart documents the benefits of continued evaluation, treatment, or observation.
• Alternatives were discussed
  Verify alternatives such as observation, outpatient follow-up, return precautions, or partial treatment were discussed.
• Patient questions and understanding documented
  Check whether the patient was given an opportunity to ask questions and demonstrated understanding of the risks and plan.
• Refusal was voluntary and free of coercion
  Verify the documentation indicates the decision was voluntary and not the result of coercion or misunderstanding.

Patient Acknowledgment and Documentation

• Patient acknowledgment of AMA discharge documented
  Confirm the chart includes patient acknowledgment, refusal statement, or equivalent documentation of leaving against advice.
• Patient signature obtained when feasible
  Verify the patient signed the AMA form or refusal documentation when feasible.
• Witness or staff signature documented when patient signature unavailable
  If the patient did not sign, confirm a witness, nurse, or physician signature was documented per policy.
• Reason signature was not obtained documented
  If no patient signature is present, document why it was unavailable, such as patient refusal, elopement, or clinical instability.
• Belongings, transport, or departure status documented
  Verify the chart notes how the patient left, including belongings, escort, transport, or elopement status when relevant.

Discharge Instructions and Follow-Up

• Return precautions documented
  Confirm the patient was instructed on symptoms or changes that should prompt immediate return or emergency care.
• Follow-up plan documented
  Verify follow-up with primary care, specialist, or outpatient services was documented when appropriate.
• Medication or pending result instructions documented when applicable
  Check whether medication instructions, pending test results, or pending callbacks were addressed before departure.
• Discharge instructions provided in understandable format
  Verify instructions were provided in a language and format the patient could understand, including interpreter use if needed.
• Follow-up barriers addressed
  Confirm the chart documents any barriers to follow-up, such as transportation, housing, or access issues, and any mitigation offered.