MDM //

The patient has made the decision to leave this Emergency Department and any ongoing care against the advice of the emergency physician. The patient has been informed of and verbalized understanding of the inherent risks of this decision, including death, disability and [***]. The patient explained to me the reason for wanting to sign out against medical advice which was [***]. The patient was given alternative therapeutic options including [***]. The patient has the capacity to make this decision and accepts the responsibility of leaving at this time. The patient and all necessary parties have been advised that the patient may return at any time for further evaluation or treatment. The patient's condition at time of discharge is [***]. AGAINST MEDICAL ADVICE The patient, has decided to refuse further care and leave against medical advice after they were offered medical screening examination; further examination, and treatment. The patient, has normal mental status and adequate capacity to make medical decisions. The patient was informed of their condition and understands the risks/harms of leaving, including disability, paralysis, sepsis/infection, loss of limbs, stroke, bleeding, heart attack, permanent disability, and death and the benefits of the above offered care, including eduction on our best medical opinion for staying for further treatment, including additional workup and/or admission, the availability and proximity of nurses, physicians, monitoring, diagnostic testing, and treatment. Even in the face of these risks the patient still desires to go home. The patient left because they did not wish to stay. The patient has had an opportunity to ask questions about his medical condition, and I answered all such questions. The patient received all treatment and management possible within the parameters of their decision and were encouraged to return for care at any time or follow up with a doctor as soon as possible. The patient has been given strict return precautions to come back to the hospital if they have worsening fever, chills, nausea, vomiting, chest pain, trouble breathing, or any other worrisome symptoms.



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