SHM Converge Scientific Abstract ePoster Gallery-Things We Are Still Doing for No Reason: Documentation of Discharge as "Against Medical Advice"

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This retrospective chart review examined how hospitalists and nurses document self-directed discharges, often still labeled “against medical advice” (AMA), at a tertiary academic medical center. Although practice guidelines recommend avoiding the AMA label because it can contribute to stigma and worse outcomes, the term remains common.<br /><br />Researchers identified 1,126 hospital medicine discharges designated as AMA between 2017 and 2023 and randomly sampled 165 cases for review. Two physicians independently reviewed each chart for patient characteristics and discharge documentation, with a third resolving disagreements.<br /><br />The study found that most clinicians still used the term AMA: 81% of hospitalist notes and 70% of nursing notes. Neutral terms such as “self-directed discharge” were used much less often, and some notes did not describe the discharge type at all. Documentation was also inconsistent for key elements of discharge decision-making. Capacity assessments were missing in 23% of cases, both capacity assessment and risk-benefit discussion were absent in 18%, and risk-benefit discussion alone was absent in 13%.<br /><br />Common documented barriers to discharge included therapeutic needs, pending diagnostic studies, and care coordination problems. Patient characteristics frequently included psychiatric disorders, homelessness or marginal housing, and substance use disorder. Documented patient reasons for leaving included disagreement with or mistrust of the treatment plan, dissatisfaction with pain control, and, in 31% of cases, no rationale was documented.<br /><br />Overall, the authors conclude that documentation practices around self-directed discharges remain incomplete and inconsistent. They call for further education and standardization to improve accuracy, patient-centeredness, and reduce bias and stigma in this marginalized population.

Asset Subtitle

Karishma Patel

Meta Tag

Author List Hadi Roudsari, Karishma Patel, Molly A. Kantor, Monisha Bhatia, Sandra Oreper, Zainab H. Apalara

Category Research

Concept Self-directed Discharge

Concept Against Medical Advice

Concept Capacity Assessment

Concept Risk-Benefit Discussion

Concept Standardized Documentation

Distinguished Non-Finalist

Presenter Organization Department of Medicine, University of California, San Francisco

Presenting Author Karishma Patel

Track Quality Improvement

Keywords

self-directed discharge

against medical advice

AMA documentation

hospitalist notes

nursing notes

retrospective chart review

capacity assessment

risk-benefit discussion

stigma reduction

patient-centered care

Self-directed Discharge

Against Medical Advice

Capacity Assessment

Risk-Benefit Discussion

Standardized Documentation