As of February 1, 2017, this policy applies to the operations and staff of legacy UWHC. Effective July 1,
2015, the legacy operations and staff of UWHC and UWMF were integrated into the University of
Wisconsin Hospitals and Clinics Authority (UWHCA). All policies are being transitioned to apply
UWHCA-wide, but until future revision to this policy #4.19, it applies only to the operations and staff of
4.19 Discharge Against Medical Advice/Elopement from Hospital
Category: UWHC Policy
Policy Number: 4.19
Effective Date: February 1, 2017
Section: Legal Affairs
To establish a procedure to be followed when a patient is discharged against medical advice (AMA) or leaves a UW
Health facility without having been discharged (i.e., elopes).
UW Health recognizes the broad right of patients to determine their own care, but also recognizes the need to
attempt to document that the patient is informed of the medical consequences of his/her decision and the need to
take steps in some cases to initiate law enforcement involvement to provide additional information to the patient or
to take the patient into custody. The determination of when to request law enforcement involvement is the
physician's responsibility. UW Health staff should assist in carrying out the physician's determination as outlined in
the following procedure.
A. Discharge Against Medical Advice (AMA).
For purposes of this policy, discharge AMA includes those circumstances when an inpatient or an
outpatient leaves AMA. When a patient requests discharge AMA, the physician responsible for the patient
should be notified immediately. Any patient requesting to be discharged AMA must be informed by a
physician of the risks and consequences of his/her leaving. This discussion between the patient and
physician must be documented in the electronic health record (EHR). If after this discussion, the patient
still insists on being discharged, staff should attempt to have the patient read and sign the AMA form
(UWH#335 ). Minors, unless they have admitted themselves, must have the consent of a parent in order
to be discharged AMA.
A patient is not allowed to discharge him or herself AMA if the patient is under commitment orders or lacks
decision-making capacity. In addition, minors, unless they have admitted themselves, may not be
discharged AMA without the consent of a parent. If a patient attempts to leave under these circumstances,
the Department of Patient Relations or the Administrator On-Call should be notified and Hospital
Security should be called for assistance (telephone 890-5555).
B. Leaving Without Being Discharged (Elopement).
When a hospitalized patient leaves the hospital without being discharged and before he/she can be
informed of the risks and consequences of such leaving:
1. The responsible registered nurse must:
a. Immediately notify Hospital Security (890-5555) and request a security camera
surveillance check. Provide the patient's name and a physical description.
b. Immediately notify the Nursing Coordinator - beeper 7576.
c. Notify Admissions/Bed Control (263-8780) who, in turn, will inform the Information
d. Notify the responsible physician.
e. Submit a report through the Patient Safety Net.
f. Note the elopement in the EHR.
g. Include time of occurrence, pertinent circumstances, and persons notified.
2. If the patient returns:
a. Note the patient's return in the EHR. Include the date, time and by whom s/he was
returned, as well as names of persons notified of his/her return.
b. Notify the physician, nursing office coordinator, Admissions/Bed Control, the family, and
3. The Nursing Coordinator must:
a. Notify Nursing Administrator On-Call who in turn will notify the Administrator On-Call.
b. If the patient is a minor who did not admit him or herself, cases of possible child
abduction shall follow Hospital Administrative policy 8.54. In all other cases, notify
Hospital Security and request assistance in locating and returning the patient to the
i. A parent, after being informed of the risk and consequences of the patient's
leaving the hospital by the responsible physician, determines that the patient
should not be returned to the hospital and;
ii. The patient's leaving the hospital does not pose a serious risk of harm to the
patient or others.
c. If the patient is an inmate, notify Hospital Security (263-7065) and the Supervisor on
Duty for Corrections (263-1322) immediately.
d. If the patient returns notify Hospital Security if that department was notified of the
elopement and is not involved in the return of the patient.
4. The responsible physician must:
a. Notify the patient's family (unless the patient is an inmate).
b. Determine if the patient's leaving the hospital poses a serious risk of harm to the patient
or to others.
c. If the patient is a minor who did not admit him or herself, cases of possible child
abduction shall follow Hospital Administrative policy 8.54. In all other cases, discuss the
risks and consequences of the patient's leaving the hospital with a parent; request
Hospital Security to assist in locating and returning the patient if:
i. The parent wishes the patient to be located and returned or
ii. The patient's leaving poses a serious risk of harm to him/herself or others.
d. For other patients, if the physician determines that the patient's leaving does not pose a
serious risk of harm to the patient or to others, the physician must document this
determination in the EHR and notify the Administrator On-Call of this determination.
e. If the physician determines that there is a serious risk of harm to the patient or others,
it is the physician's responsibility to make the decision whether or not to request police
assistance. Police assistance will be requested if the physician considers the patient
suicidal, incompetent, homicidal or a threat to public health by reason of a
communicable disease. Police assistance may be requested to locate patients who left
without being aware of serious risk to themselves.
5. Usual police procedure is to look for a patient; if they locate him/her, they attempt to verbally
persuade him/her to return to the hospital. For patients hospitalized on Psychiatry, if the patient
refuses to return and the physician believes that hospitalization is necessary, a Statement of
Emergency Detention will be prepared if appropriate.
IV. FORMS USED
Statement of Emergency Detention
AMA Form (UWH #335)
Sr. Management Sponsor: Sr. VP, General Counsel
Author: General Counsel
Approval Committee: UW Health Clinical Policy Committee
Peter Newcomer, MD
Chief Clinical Officer
J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee