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1. Reason: The patient has decided to leave against medical advice because .

2. Capacity: The patient has normal mental status and adequate capacity to make medical decisions.

3. Refusal: The patient refuses hospital admission and wants to be discharged.

4. Risks: Risks have been explained including , worsening illness, permanent disability and death.

5. Benefits: Benefits of admission have also been explained

6. Understanding: The patient verbalized understanding the risks and benefits of hospital admission.

7. Witnesses: Nurse and family .

8. Questions: The patient had the opportunity to ask questions about their medical condition.

9. Plan B: The patient was treated to the extent they allow and knows they may return at any time

10. Follow-up: If possible the patient’s PCP was called to help try to convince them to stay in the hospital and to arrange appropriate follow-up care.

from emresource.org

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