ama nursing note example

3 min read 11-03-2025

Meta Description: Learn how to write a proper AMA (Against Medical Advice) nursing note with this comprehensive guide. Includes examples, best practices, and essential elements for accurate and legally sound documentation. Avoid common pitfalls and ensure your notes are compliant. Protect yourself and your patients by mastering AMA documentation.

Introduction:

Leaving a healthcare facility against medical advice (AMA) is a serious event requiring meticulous documentation. A well-written AMA nursing note protects both the patient and the healthcare provider. This article provides examples and best practices to ensure your documentation is accurate, comprehensive, and legally sound. Understanding how to write a thorough AMA nursing note is crucial for any nurse.

What Constitutes Leaving AMA?

A patient leaves AMA when they choose to discontinue treatment or leave the healthcare facility before their medical team deems it appropriate. This decision is made despite advice from medical professionals to remain for further observation, treatment, or testing. The reasons behind a patient's decision to leave AMA are varied and can range from personal preference to financial constraints.

Essential Elements of an AMA Nursing Note

Every AMA nursing note should include specific details to provide a clear picture of the situation. These are essential for legal and medical purposes. Missing information can lead to liability issues.

1. Patient Identification

Full Name: Clearly identify the patient using their full legal name.
Medical Record Number (MRN): Include the patient's unique MRN for easy retrieval of their file.
Date and Time: Precisely document the date and time the patient left AMA.

2. Documentation of the Attempt to Persuade

Individuals Involved: Note who spoke to the patient (doctor, nurse, etc.).
Discussion Points: Outline the discussion. Explain the risks of leaving AMA. Detail the recommended treatment and potential consequences.
Patient's Response: Record the patient's exact response. Include their reasons for leaving. Avoid subjective interpretations.

3. Patient's Condition at Time of Discharge

Vital Signs: Document the patient's vital signs (temperature, pulse, respirations, blood pressure, oxygen saturation) immediately before departure.
Physical Assessment: Briefly note the patient's physical condition. Include any relevant observations. For example, level of consciousness, pain level, and overall appearance.
Mental Status: Describe the patient's mental state (alert, oriented, confused, etc.).

4. Instructions Provided to the Patient

Medication Instructions: Note any medications the patient was taking and instructions provided. Include dosage and frequency.
Follow-up Appointments: Record any scheduled follow-up appointments, including dates, times, and providers.
Emergency Contact Information: Document the patient's emergency contact information.
Warning Signs: Explain any warning signs to watch for and when to seek immediate medical attention.

5. Witness Signatures

Patient Signature: Ideally, obtain the patient's signature acknowledging they are leaving AMA.
Witness Signature: A nurse or other authorized healthcare professional should witness and sign the document.

AMA Nursing Note Example

Patient Name: Jane Doe MRN: 1234567 Date: October 26, 2024 Time: 14:30

At 14:00, I, Nurse Smith, attempted to discuss the risks associated with leaving the hospital against medical advice with Jane Doe. Dr. Jones previously explained the need for further observation due to her unstable blood pressure. Ms. Doe stated she felt well enough to leave and was concerned about the cost of her hospital stay. Despite explanations of potential complications and the importance of continued monitoring, Ms. Doe insisted on leaving.

Vital Signs (prior to leaving):

Temperature: 98.6°F (oral)
Pulse: 88 bpm
Respirations: 16 breaths/min
Blood Pressure: 130/80 mmHg
O2 Saturation: 99% on room air

Physical Assessment: Alert and oriented x3. No acute distress noted.

Ms. Doe was advised to follow up with her primary care physician within 24 hours. She was given instructions regarding her medications (list medications and instructions). Emergency contact information was confirmed. Ms. Doe was instructed to seek immediate medical attention if she experienced chest pain, shortness of breath, or dizziness.

Patient Signature: _________________________ Witness Signature: _________________________ (Nurse Smith, RN)

Legal and Ethical Considerations

Accurate and thorough documentation is crucial for legal protection. It demonstrates that appropriate care and counseling were provided. Hospitals have policies and procedures regarding AMA discharges. Always adhere to your institution's guidelines. If you are unsure about any aspect of documenting an AMA, consult with your supervisor or a legal professional.

Conclusion

Writing a comprehensive AMA nursing note is vital for patient safety and legal protection. By following the guidelines and using the example provided, nurses can ensure accurate and legally sound documentation. Remember, clear and thorough documentation minimizes risk and protects both the patient and the healthcare team. Always prioritize patient safety and adhere to your institution’s policies and procedures.