Informed Refusal/AMA

Chart reflected you cared about getting the patient the care that they needed.

5 Elements:

1. Adult or emancipated minor

2. Sound mind – Mentation, understanding etc. Involve collateral from family to corroborate normal mental status. Document if informed in front of family.

3. Explained in consequences in lay terms – “The patient expressed he understood he could did”

4. If there are reasonable options, they have been offered – Another test, treat empirically, etc.

5. Involve other people – family members, staff etc.

6. Signature – from pt, wife, family, staff etc.