CCAHN - California Critical Access Hospital Network



POLICY:

When any patient leaves against medical advice (AMA) or elopes, it is the policy of the hospital to act in accordance with the welfare of the patient and the public while respecting the patient’s rights.

Leaving Against Medical Advice (AMA):

Whenever a patient states that he or she intends to leave the hospital before the physician has ordered the patient’s discharge, the attending physician should be contacted immediately. The attending physician should be asked to discuss the request with the patient, either by telephone or in person, as appropriate.

If the patient attempts to leave the hospital before discussing the matter with his or her physician, hospital personnel should inform the patient that his or her attending physician has been contacted and will explain the risks and consequences of leaving the facility to the patient before he or she leaves.

Whenever a demand is made by a patient (or the patient’s legal representative) to leave the hospital before treatment is completed or contrary to the advice of the attending physician or of a staff physician of the hospital, “Leaving Hospital Against Medical Advice” should be completed. This form documents that the patient was given information regarding possible risks that may result from a decision to leave against medical advice, the benefits of continued hospitalization and any alternatives and that the patient nevertheless decided to leave.

The hospital should take proper precautions to ensure that the patient leaves the hospital in a safe manner. The responsible physician should be involved in the arrangements; the physicians are required to take reasonable steps to protect their patients from dangerous conduct. For example, the patient may be warned that it would be dangerous for the patient to drive because of his or her medical condition or medication the patient has taken. The hospital may require the patient to be taken to the hospital exit in a wheelerchair. It may be prudent to arrange for transportation that is appropriate in view of the patient’s condition (e.g. taxi or an ambulance).

Hospital personnel should carefully document the facts surrounding the patient’s departure and specifically note the actions that were taken to assure the patient’s safety and the basis for the determination that the actions were appropriate.

Definition of AMA vs. Elopement vs. Left Without Being Seen:

|AMA = Disposition “07” |LWBS/Eloped = Disposition “99” |

|A patient or patient’s representative talks with the physician they |Emergency Room: |

|leave against the physician’s advice. |NO discharge order and NO discussion between the physician and |

| |patient/patient rep. |

|There must be an actual discussion between patient/patient rep and the|Patient left prior to a medical screening exam by the physician. |

|physician. |Signed in to be seen in the emergency room and left prior to Triage. |

| | |

| |Inpatient/Resident: |

| |Elopement is defined as the unauthorized absence of an admitted |

| |patient, acute or long-term care, from the boundaries of the |

| |Medical/Surgical care unit without staff knowledge. |

PROCEDURE:

Any Patient:

▪ Elopement can be a planned or totally impulsive act. Some risk factors to look for to determine whether a patient is at risk and requires very close supervision:

- The patient exhibits confusion related to one or more of the following physical

issues:

*Dementia

*Traumatic brain injury

*History of alcohol or drug abuse

*Metabolic changes

- The patient has a history of elopement in this or a prior hospitalization.

- The patient or family members have been angry about care issues and have

threatened to leave.

- The patient has a history of substance abuse and may be craving the

substance of abuse (drugs, alcohol).

- The patient has a history of wandering.

- The patient has been visited by friends or family who are encouraging him/her

To leave for family or social issues

▪ After consideration of the above risk factors and the patient’s condition, and using professional judgment, if it is determined that the patient may be a danger to himself/herself or others the Tehachapi Police Department should be promptly notified.

▪ If the patient is not competent, the conservator or guardian should be contacted immediately and informed of the elopement.

▪ If a patient is in the process of eloping from the facility, staff should encourage the patient to remain.

▪ The ERMD should, if possible, explain the risks and consequences associated with leaving the facility. The patient should be asked to sign the “Informed Consent to Refuse” or the “AMA” form. Document the conversation with the patient in the medical record.

▪ If the patient states why they are leaving the facility, document the patient’s statement in the medical record.

AMA and LWBS/Elopement Examples and Coding:

▪ Emergency Department: Any patient, who has been seen by the Triage Nurse but left prior to an evaluation (Medical Screening Examination) by the Emergency Department physician, is considered “left without being seen/ eloped” and discharge disposition would be entered as, # 99.

▪ A patient who signed in to be seen in the ED and left before triage would be also considered to have “left without being seen/ eloped” and code 99 would also be entered as the discharge disposition.

▪ A patient who is evaluated by the physician, the physician has advised the patient to stay and the patient chooses to leave against the physician’s advice is an AMA. Discharge disposition would be entered in Mardon as “Left AMA”, # 07.

Documentation:

▪ The following will be documented:

Time of triage

Time seen by the physician, if applicable

If observed, time patient left Emergency Department

If patient departed or eloped prior to treatment or disposition

For AMA patients, documentation will include a completed AMA form or include documentation regarding inability to obtain signed “AMA” form.

Discharge disposition will be circled on the ED Charge sheet.

References: Consent Manual, California Hospital Association, Chapter 5 and 9

Emergency Department Call-Back Form, NSG 97

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