ama nursing note example

Daniel Parker

3 min read

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02-03-2025

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Meta Description: Learn how to write a comprehensive and legally sound Against Medical Advice (AMA) nursing note. This guide provides examples, key elements, and best practices for documenting patient departures against medical recommendations. Includes tips for avoiding legal pitfalls and ensuring accurate charting.

Understanding AMA Documentation

An Against Medical Advice (AMA) nursing note is a crucial legal and medical record documenting a patient's decision to leave a healthcare facility before medical professionals deem it appropriate. Accurate and complete documentation protects both the patient and the healthcare provider. This article provides examples and guidance for creating effective AMA nursing notes.

Key Elements of an Effective AMA Note

Several essential components must be included in every AMA nursing note. Missing even one element can weaken the note's legal standing. Here's a breakdown:

• Date and Time: Precisely record the date and time the patient chose to leave against medical advice.
• Patient Identification: Clearly identify the patient using their full name and medical record number.
• Reason for Admission: Briefly state why the patient was admitted to the facility.
• Physician's Recommendations: Detail the physician's recommendations regarding continued care and the potential risks of leaving. Include specific advice given to the patient.
• Patient's Understanding: Document that the patient understood the risks associated with leaving AMA. Note how this understanding was conveyed (e.g., verbal explanation, written materials).
• Patient's Statement: Include the patient's stated reason for leaving against medical advice. Quote the patient directly whenever possible.
• Witness: Note the presence of any witnesses to the conversation and the patient's decision. Include their names and titles.
• Nursing Assessment: Document the patient's condition before departure. Include vital signs, mental status, and any observed physical issues.
• Patient Signature (if possible): Obtain the patient's signature acknowledging their understanding and decision. If the patient refuses to sign, note this refusal in the record.
• Family/Guardian Involvement (if applicable): If family members or guardians were involved, mention their roles and any relevant input.

AMA Nursing Note Examples

Here are a few examples illustrating different scenarios:

Example 1: Simple AMA Note

"03/08/2024, 14:30: Patient John Doe (MRN 1234567), admitted for chest pain, decided to leave AMA despite physician's recommendation for continued observation and cardiac testing. The physician explained the risks of leaving, including potential cardiac complications. The patient stated he felt 'fine' and wished to go home. Patient refused to sign AMA form. Witnessed by Nurse Jane Smith, RN."

Example 2: AMA Note with Detailed Assessment

"10/26/2024, 09:00: Patient Jane Smith (MRN 8765432), admitted for pneumonia, chose to leave AMA despite physician's recommendation for completion of antibiotic course. The physician explained the increased risk of infection recurrence and potential complications. Patient stated she felt 'better' and wanted to go home. Patient's vital signs prior to leaving: BP 120/80, HR 80, RR 16, SpO2 98% on room air. Patient signed AMA form. Witnessed by Dr. David Lee, MD."

Example 3: AMA Note with Family Involvement

"12/15/2024, 16:45: Patient Mary Brown (MRN 9876543), admitted for a fractured femur, decided to leave AMA against physician's advice for continued pain management and physical therapy. The physician explained the potential for increased pain and complications. Patient stated she wanted to go home to be with her family. Her daughter, Sarah Brown, was present and supportive of the decision. Patient's vital signs were stable. Patient signed AMA form. Witnessed by Nurse Emily Jones, RN."

Legal Considerations and Best Practices

Accurate documentation is paramount in protecting healthcare professionals from liability. Here are some crucial best practices:

• Avoid judgmental language: Remain objective and factual in your descriptions.
• Use clear and concise language: Avoid medical jargon.
• Ensure proper grammar and spelling: Mistakes can undermine credibility.
• Review and correct errors promptly: If a mistake is noticed, correct it according to your facility's policy.
• Consult with your supervisor: If unsure about any aspect of the documentation process, seek guidance from your supervisor or legal counsel.

By following these guidelines and examples, you can create comprehensive and legally sound AMA nursing notes, ensuring both patient safety and protection for healthcare providers. Remember, consistent, accurate documentation is critical. Consult your facility's policies and procedures for specific guidance.