A nurse is providing care for a client who is unhappy with the health care provider's care. The client signs the Against Medical Advice (AMA) form and leaves the hospital against medical advice
The nurse should include which of the following in the documentation of this event in the client's medical record or on the AMA form? Select all that apply. 1. Documentation that the client has been informed that he or she is leaving against medical advice.
2. Documentation of explanation of the risks of leaving against medical advice.
3. Documentation of any discharge instructions given to the client.
4. Documentation indicating an incident report has been completed.
5. Documentation that the client has been informed that he or she cannot come back to the hospital.
1. Documentation that the client has been informed that he or she is leaving against medical advice.
2. Documentation of explanation of the risks of leaving against medical advice.
3. Documentation of any discharge instructions given to the client.
Rationale:
Documentation that the client has been informed that he or she is leaving against medical advice. It should be clearly documented that the patient has been advised that he or she is leaving against medical advice in the client's record as well as on the AMA form. Documentation of explanation of the risks of leaving against medical advice. It should be clearly documented that the client understands the risks of leaving on the AMA form. Documentation of any discharge instructions given to the client. The AMA form includes the name of person accompanying the client and any discharge instructions given. Documentation that the client has been informed that he or she cannot come back to the hospital. It should be clearly documented that the client been advised and understands that he or she can come back. Documentation indicating an incident report has been completed. Facility policy may require that an incident report be completed, but it must not be referenced in the chart. The client's record is a legal document, so the nurse should never document that he or she filed an incident report.
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