Run Discharge Against Medical Advice Documentation Audit — Free

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 critical (required)

Verify the record clearly indicates the patient left AMA, refused recommended care, or an equivalent documented disposition.

Yes No N/A

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 critical (required)

Verify the note includes an assessment of the patient's ability to understand, appreciate, reason about, and communicate a choice regarding leaving.

Yes No N/A

Mental status or factors affecting capacity addressed critical (required)

Check whether intoxication, delirium, pain, psychiatric symptoms, language barriers, or other factors affecting capacity were considered.

Yes No N/A

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.

Yes No N/A

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.

Yes No N/A

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 critical (required)

Verify the record states the patient was informed of material risks, including worsening condition, disability, complications, or death when applicable.

Yes No N/A

Benefits of staying or completing treatment were explained

Confirm the chart documents the benefits of continued evaluation, treatment, or observation.

Yes No N/A

Alternatives were discussed

Verify alternatives such as observation, outpatient follow-up, return precautions, or partial treatment were discussed.

Yes No N/A

Patient questions and understanding documented critical (required)

Check whether the patient was given an opportunity to ask questions and demonstrated understanding of the risks and plan.

Yes No N/A

Refusal was voluntary and free of coercion

Verify the documentation indicates the decision was voluntary and not the result of coercion or misunderstanding.

Yes No N/A

Patient Acknowledgment and Documentation

Patient acknowledgment of AMA discharge documented critical (required)

Confirm the chart includes patient acknowledgment, refusal statement, or equivalent documentation of leaving against advice.

Yes No N/A

Patient signature obtained when feasible

Verify the patient signed the AMA form or refusal documentation when feasible.

Yes No N/A

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.

Yes No N/A

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.

Yes No N/A

Discharge Instructions and Follow-Up

Return precautions documented critical (required)

Confirm the patient was instructed on symptoms or changes that should prompt immediate return or emergency care.

Yes No N/A

Follow-up plan documented

Verify follow-up with primary care, specialist, or outpatient services was documented when appropriate.

Yes No N/A

Medication or pending result instructions documented when applicable

Check whether medication instructions, pending test results, or pending callbacks were addressed before departure.

Yes No N/A

Discharge instructions provided in understandable format

Verify instructions were provided in a language and format the patient could understand, including interpreter use if needed.

Yes No N/A

Follow-up barriers addressed

Confirm the chart documents any barriers to follow-up, such as transportation, housing, or access issues, and any mitigation offered.

Yes No N/A

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Run: Discharge Against Medical Advice Documentation Audit

Audit Details

Capacity Assessment

Risk Explanation and Informed Refusal

Patient Acknowledgment and Documentation

Discharge Instructions and Follow-Up

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