Question 1

The nurse is providing care for a patient who is unhappy with the health care provider’s care.

The patient signs the Against Medical Advice (AMA) form and leaves the hospital against

medical advice. What should the nurse include in the documentation of this event in the

patient’s medical record or on the AMA form?

1. Documentation that the patient was informed that he or she cannot come back to the

hospital

2. Documentation that the patient was informed that he or she was leaving against medical

advice

3. Documentation that the risks of leaving against medical advice were explained to the

patient

4. Documentation of any discharge instructions given to the patient

5. Documentation indicating an incident report has been completed

Correct Answer: 2,3,4

Rationale 1: It should be clearly documented that the patient was advised and understands

that he or she can come back.

Rationale 2: It should be clearly documented in the patient’s record and on the AMA form

that the patient was advised that he or she was leaving against medical advice.

Rationale 3: It should be clearly documented that the patient understands the risks of leaving

against medical advice.

Rationale 4: The AMA form includes the name of the person accompanying the patient and

any discharge instructions given.

Rationale 5: Facility policy may require that an incident report be completed, but it must not

be referenced in the chart. The patient’s record is a legal document, so the nurse should

never document that he or she filed an incident report.

Question 2