UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
TITLE: Leaving Against Medical Advice (AMA)
Effective Date: October, 2011 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education
Reviewed May, 2012
PURPOSE: The purpose of this guideline is to specify the process for responding to a
patient/legal guardian's refusal to follow a University of Wisconsin Medical Foundation
(UWMF ) providers (MD/NP/PA) recommendation for treatment in the outpatient setting.
POLICY STATEMENT: The provider and clinical staff will utilize the following guideline to
communicate recommendations to a patient/legal guardian in providing care or a need to transfer
to another facility for advanced care. While the UWMF honors an individual's right to refuse
treatment, UWMF will document the refusal of treatment/transfer in the patient’s medical record.
SUPPLIES: Acknowledgment of Discharge Against Medical Advice form via Uconnect (link)
1. Assess patient’s need to remain on-site or be transferred to an advanced care facility for
further medical care or treatment.
2. Communicate to patient or legal guardian in a clear and concise manner the need for
further treatment, evaluation or transfer for advanced medical care.
3. If patient or legal guardian refuses treatment/transfer, inform patient or legal guardian
that a refusal form will need to be signed.
4. Inform patient or legal guardian that the Acknowledgment of Discharge Against Medical
Advice form will become part of their medical record.
5. Complete the form in full, including patient’s and provider’s full name.
6. Obtain patient/legal guardian’s signature and date on the form.
7. Obtain a witness signature.
8. Make a copy of the signed and dated form for the patient or legal guardian.
9. Document in the patient’s medical record using HealthLink smart phrase (.amadoc).
Documentation will include:
specific care declined
potential risks discussed; including the most likely and significant risks
o if necessary use the wording ‘including’ if there are too many
risks to document
completion of or refusal of patient to complete the refusal form
patient or legal guardian received a copy of form
10. Forward the original Acknowledgment of Discharge Against Medical Advice
form to HIS Scanning 414 for scanning into the patient’s medical record.
11. Forward a copy of Acknowledgment of Discharge Against Medical Advice
form to UWMF Legal Department for the following situations:
If the patient is a minor, incompetent or unable to consent on his or her own behalf
for any reason.
The patient is pregnant and her fetus in endangered.
Patient’s refusal is likely to result in his or her death.
WRITTEN BY: LaVay Morrison, RN, BSN, Clinical Staff Educator
Ronnie Peterson, RN, MSN, Manager of Clinical Support
REVIEWED BY: Rebecca Hutton, UWMF Associate Legal Counsel II
1. UWHC Policy #4.19 Discharge Against Medical Advice/Elopement from Hospital
2. UWHC Policy #7.12 Emergency Assessments at UWHC Facilities.
Against Medical Advice/Elopement from Hospital
Medical Director Date