• Marie Rymut Schaefer and Edward P Monico.
• Yale School of Medicine, New Haven, USA.
• Conn Med. 2013 Sep 1;77(8):461-6.

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

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