ama nursing note example

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09-03-2025

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AMA Nursing Note Example: Documenting Against Medical Advice

A patient's decision to leave a healthcare facility against medical advice (AMA) requires meticulous documentation. Accurate and complete nursing notes are crucial for legal protection, continuity of care, and informing future treatment decisions. This article provides an example of a well-written AMA nursing note, highlighting key elements to include.

Scenario: A 68-year-old male patient, Mr. John Smith, admitted for chest pain and shortness of breath, decides to leave the hospital AMA despite physician recommendations for further observation and testing.

Example AMA Nursing Note:

Date: October 26, 2023 Time: 14:30 Patient: John Smith, Medical Record Number: 1234567 Note:

At 14:00, I approached Mr. Smith regarding his expressed intent to leave the hospital against medical advice. I explained the risks associated with leaving before completing the recommended diagnostic testing and treatment for his chest pain and shortness of breath. Specifically, I discussed the potential for:

• Unstable angina: The risk of a worsening cardiac event, including myocardial infarction.
• Pulmonary embolism: The possibility of a blood clot in the lungs, potentially life-threatening.
• Delayed diagnosis and treatment: The potential for delaying the identification and treatment of an underlying medical condition.

I offered to answer any questions he had and provided him with information regarding follow-up care options. Mr. Smith stated he understood the risks involved but wished to leave the hospital at this time due to [insert patient's reason here. Be precise and objective. For example: "personal reasons," "concerns about cost," or "desire to be at home."]. He reported feeling "better" and stated he would follow up with his primary care physician.

I reiterated the importance of seeking immediate medical attention should his symptoms worsen. I documented his vital signs at this time: BP 120/80 mmHg, HR 72 bpm, RR 16 breaths/min, SpO2 98% on room air. He appeared alert and oriented to person, place, and time. He signed the AMA form (copy attached to chart) at 14:25, acknowledging he understood the risks and was leaving against medical advice. A copy of the AMA form was provided to the patient. The physician, Dr. Jane Doe, was notified of Mr. Smith's decision.

Key Elements of a Comprehensive AMA Note:

• Patient Identification: Clearly identify the patient using name and medical record number.
• Date and Time: Record the precise date and time of the interaction.
• Attempts to Persuade: Document efforts made to persuade the patient to stay, including the specific risks explained.
• Patient's Reasoning: Objectively document the patient's reason for leaving AMA. Avoid subjective interpretations.
• Assessment: Include the patient's vital signs and overall assessment (alertness, orientation).
• Informed Consent: State that the patient was informed of the risks and signed the AMA form.
• Physician Notification: Note that the physician was informed of the patient's decision.
• Follow-up Plan (if any): Document any agreed-upon follow-up plan, including referrals or recommendations.
• Objective Language: Use factual and neutral language throughout the note. Avoid emotional or judgmental statements.

This example highlights the necessary components of a thorough AMA nursing note. Remember, meticulous documentation protects both the healthcare provider and the patient. Always adhere to your facility's specific policies and procedures regarding AMA departures.