Documentation

AMA Discharge Documentation Tool

A bracketed-prompt scaffold for a defensible against-medical-advice note you finish and sign yourself.

Documentation prompt only — not legal or clinical advice. Runs entirely in your browser. Drafts autosave locally; nothing is sent. Do not paste patient identifiers (names, DOB, MRN, insurance numbers) — even short direct quotes can be identifying. This tool does not determine decisional capacity and does not replace your program's AMA form.

Setting & capacity

SettingCapacity concern

Risks discussed with patient

Death (overdose, withdrawal complication, or untreated condition)Seizure or other withdrawal complicationOverdose / relapse with elevated post-treatment riskWorsening of underlying psychiatric conditionWorsening of underlying medical conditionLoss of medication continuity (MOUD, psychiatric, medical)Loss of insurance authorization for re-admission

Other risk discussed (optional)

Teach-back captured — patient repeated back the main risks in their own words.

Alternatives offered

Continued stay at current level of careStep-down to a lower level of careTransfer to a different facility / specialty consultReturn precautions and follow-up appointmentMOUD continuation / referralOpen-door / re-entry offered

Other alternative offered (optional)

Harm-reduction mitigations provided

Naloxone dispensed / prescribedOverdose recognition / response educationWritten warning-signs handoutFollow-up appointment scheduledWarm handoff to outpatient providerEmergency contact notified (with patient consent)

Other mitigation (optional)

People present, reason, and observations

Persons present (one per line — role + initial preferred; no full names)Patient's stated reason for leaving (in patient's own words if quoted)Mental status / clinical observations at the time of the discussion

Disposition & times

DispositionTime AMA discussion beganTime patient departed (or eloped)

Note scaffold

updates live

Clinician's narrative note, not a replacement for your program's AMA form.

CLINICAL NOTE — Against Medical Advice (AMA) discussion and departure
Date: 2026-05-28
Program / setting: SUD residential / inpatient
Clinician: [INSERT: name, credentials, role, NPI]
Time of AMA discussion: [INSERT]    Time of departure: [INSERT]

ENCOUNTER SUMMARY
Patient indicated intent to leave the program against medical advice. The conversation below took place at the bedside / in the office and is documented contemporaneously. [INSERT: brief context — what triggered the conversation, who initiated it.]

DECISIONAL CAPACITY
Capacity to refuse this specific intervention was assessed in the moment. Capacity is decision-specific. The following capacity abilities were considered:
  1. Ability to communicate a choice — [INSERT: specific observation, e.g., 'patient stated clearly and repeatedly the intent to leave']
  2. Ability to understand the relevant information — [INSERT: specific observation, e.g., 'patient summarized in own words the recommended treatment and the reasons for it']
  3. Ability to appreciate the situation and its likely consequences — [INSERT: specific observation, e.g., 'patient acknowledged that leaving carries the risks discussed and applied those risks to own situation']
  4. Ability to reason about treatment options — [INSERT: specific observation, e.g., 'patient compared continued stay with leaving and articulated trade-offs']

Clinician's bottom-line capacity judgment: [INSERT: your capacity judgment for this specific decision, with the observations that support it.]

INFORMATION DISCLOSED — RISKS OF LEAVING
The patient was informed of the following risks of leaving treatment at this time:
  - [INSERT: the specific risks discussed with the patient, in plain language.]

PATIENT'S UNDERSTANDING (TEACH-BACK)
Teach-back was not captured in the moment. [INSERT: explain why — patient declined further discussion, situation did not permit, etc. — and document any other evidence of understanding, such as the patient's articulation of trade-offs or specific concerns about staying.]

ALTERNATIVES OFFERED
  - [INSERT: the specific alternatives offered to the patient — continued stay, step-down, transfer, return precautions, medication continuity, re-entry offer.]

HARM-REDUCTION MITIGATIONS PROVIDED
  - [INSERT: mitigations provided at departure — naloxone, overdose education, follow-up appointment, warm handoff, etc.]

PATIENT'S STATED REASON FOR LEAVING
[INSERT: patient's stated reason in own words. A short direct quote is helpful where possible.]

MENTAL STATUS AND CLINICAL OBSERVATIONS AT THE TIME
[INSERT: alertness and orientation, speech, thought process, mood and affect, evidence or absence of intoxication or withdrawal, contemporaneous vitals, instrument scores from the chart by name and date (e.g., the contemporaneous CIWA-Ar or COWS score from the chart on [date and time]), suicidal/homicidal ideation status on direct questioning.]

PERSONS PRESENT
  - [INSERT: each person present, by role and first-name initial (e.g., 'RN T.', 'Counselor M.').]

DISPOSITION
Patient signed the program's AMA form and departed. The signed form is filed in the chart. [INSERT: witness name/role if applicable.]

RE-ENTRY AND FOLLOW-UP PLAN
[INSERT: state the open-door offer (if any), the scheduled follow-up appointment date/time and provider, any prescriptions sent or continuity-of-care steps initiated, and how the patient can re-engage with this program.]

SAFETY AND MANDATED-REPORTING CONSIDERATIONS
The following categories were considered. Document the response where applicable, or note that the category was considered and did not apply.
  - Child present and safety concern: [INSERT or 'considered, did not apply'.]
  - Impaired-driving concern (patient leaving impaired with intent to drive): [INSERT or 'considered, did not apply'.]
  - Suicidal or homicidal ideation, or grave disability: [INSERT or 'considered, did not apply'. If present, document the protective action taken rather than proceeding as a routine AMA.]
  - Elopement notification per program policy (if applicable): [INSERT or N/A.]
  - State-specific mandated reporting: [INSERT or 'considered, did not apply'.]

42 CFR PART 2 — DISCLOSURE NOTE
This patient is in a Part-2-protected program. Any disclosure of the patient's SUD status to outside parties (family, outpatient providers, law enforcement responding to an elopement) requires valid written consent or an applicable exception. The medical-emergency exception (42 CFR 2.51) permits disclosure necessary to address a bona fide medical emergency; the act of leaving against advice is not, by itself, a medical emergency. [INSERT: document any disclosure made, the recipient, the legal basis (consent on file dated [MM/DD/YYYY] or specific exception invoked), and the information disclosed.]

ATTESTATION
This note reflects my contemporaneous documentation of the AMA discussion and departure. The program's AMA form (where signed) is filed separately in the chart and supplements but does not replace this narrative.

— [INSERT: Clinician name, credentials, NPI]
  [INSERT: signature / electronic signature timestamp]

Drafts autosave to this browser only. Nothing is sent.

Bracketed prompts like [INSERT: …] mark spots you must fill in before signing.

General information, not medical or legal advice.This produces a drafting scaffold for a clinician's narrative note documenting an against-medical-advice discussion and departure. It does not determine decisional capacity, does not replace your program's own AMA form, and does not substitute for clinician judgment, program policy, or state law. You are responsible for the clinical accuracy of anything you add, for handling patient-identifying information appropriately under HIPAA and 42 CFR Part 2, and for following your licensing board, program policies, and applicable statutes. The tool does not reproduce MacCAT-T, CAM, MoCA, MMSE, CIWA-Ar, COWS, or any specific institution's AMA form; cite your own program's contemporaneous chart findings and have the patient sign your program's actual AMA form separately.