What is expected to be documented when a patient leaves against medical advice?

When a patient leaves against medical advice, it is crucial to document the event in both progress notes and the discharge summary to provide a comprehensive record of the circumstance and the patient’s specific decision. This documentation serves several important purposes.

First, it captures the clinical rationale and the discussions that occurred before the patient’s departure, including any risks that were communicated to the patient about leaving without the care recommended by the healthcare team. This documentation helps protect the healthcare provider and the organization by demonstrating that they took appropriate steps to inform the patient of potential consequences, thereby ensuring that the patient's choice was made with an understanding of the associated risks.

Additionally, thorough documentation in the patient's medical records ensures continuity of care should the patient return to the facility in the future. Other healthcare providers reviewing the patient's history will have a clear understanding of their prior treatment and decisions made.

While incident reports, formal complaints, or notifications to risk management may be relevant in certain situations, they do not directly fulfill the requirement of accurately documenting the patient’s exit from care and the associated clinical decision-making process. Therefore, the most essential and appropriate response regarding documentation when a patient leaves against medical advice is to include it in both the progress notes and discharge summary.