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Conn Med. 2013 Sep;77(8):461-6.

Documentation proficiency of patients who leave the emergency department against medical advice.

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Yale School of Medicine, New Haven, USA.



This study describes the current documentation practices of health-care providers in the emergency department (ED) during the discharge against medical advice (AMA) process.


This retrospective cohort study reviewed health care provider documentation of adult patients who left an ED AMA in one year. Each encounter documentation was reviewed for eight medicolegal standards including the documentation of 1) the patient's capacity; 2) the signs and symptoms; 3) the extent and limitation of the evaluation; 4) the current treatment plan, risks, and benefits; 5) the risks and benefits of forgoing treatment; 6) the alternatives to suggested treatment; 7) the explicit statement made by the patient who left AMA, as well as the explicit documentation of what the patient was refusing; and 8) the follow-up care including discharge instructions.


There were 81,038 eligible ED encounters with a total of 418 patients identified as having left AMA resulting in an AMA discharge rate of 0.52%. No single chart fulfilled all eight medicolegal standards. Minimal standards established by the Emergency Medical Treatment and Active Labor Act (EMTALA) were fulfilled in only 17 charts (4.1%). Despite general acceptance in the legal and policy literature on the need to ensure capacity to make decisions, only 22.0% of the charts documented that the patient had such capacity.


This study revealed suboptimal documentation in AMA cases by clinicians at a single ED and confirms disparities between federal and academic quality (safety documentation requirements and actual provider documentation).

[Indexed for MEDLINE]

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