Against Medical Advice Form: Informed-Refusal Documentation Checklist

An against medical advice form records a patient’s decision to decline recommended care. A useful record identifies the specific recommendation, the capacity assessment, the discussion of benefits, risks and alternatives, and the continuing care plan. A signature alone cannot capture that process. ACEP Now’s informed-refusal guidance emphasizes the discussion, reasonable alternatives and follow-up.

Download the printable worksheet, download the fillable PDF, or copy the prompts below. Both PDFs have three Letter-size pages.

Sources checked October 28, 2026. This guide covers adult emergency and acute-care documentation, with separate U.S. and Ontario guidance.

Copyable against medical advice documentation form

The worksheet separates the care decision, evidence of the conversation, and follow-up ownership. Record findings, instructions and capacity conclusions from the completed assessment, and mark unassessed items as “not assessed.”

The printable worksheet and fillable version put the decision and capacity assessment on page one, the discussion and signature record on page two, and departure and follow-up on page three. Repeat the encounter identifier on each page. Use continuation entries when the discussion needs more space, with the same identifier, author and time.

For typed completion, download the fillable PDF to an approved location and open it in a PDF reader that supports form fields. Save a copy, reopen it and check every answer before printing or placing it in the record. Put longer responses in a linked continuation entry. Enter participant names in the PDF and complete authentication through the clinical record.

Map the fields to the consent policy and EHR workflow. Identify who assesses capacity, who authenticates the note, where signatures are retained, and how pending-result tasks stay visible after discharge.

Start with the specific decision

“Refused treatment” leaves the reader guessing. Was the person declining another blood draw, admission, transfer, a particular medication, or all further assessment? Identify the recommendation and the patient’s response separately. A person who declines admission may still accept prescriptions, instructions or another reasonable plan.

Use a short decision record:

• Recommendation: what the clinician proposed, why, and which uncertainty it would address.
• Decision: the exact element declined and the patient’s stated reason.
• Accepted care: what the patient agreed to and what was actually provided.
• Unfinished work: what remains unperformed, pending or awaiting review.

For example, “Declines the recommended repeat blood test and continued observation; accepts written instructions” is more informative than “refuses all care.” Neither wording should imply that the clinician considers the evaluation complete.

Ask about the reason for leaving without turning it into a judgment about character. Childcare, cost concerns, communication difficulties or an unmet need may change which alternatives are workable. The 2023 American Family Physician discussion describes a patient-centered approach to conflict, capacity and safer discharge planning. Record the barrier, assistance offered and response, including an alternative the person declined.

Document capacity and understanding

Capacity concerns the particular decision at the particular time. ACEP’s capacity guidance identifies communicating a choice, understanding, appreciation and reasoning. General orientation questions alone are insufficient. Record evidence from the actual assessment, not a prefilled “alert and oriented, therefore capable” sentence. ACEP: The Capacity to Understand Capacity, 2019

The following are original prompts for documenting the clinician’s assessment:

Record communication assistance and factors affecting the assessment, as well as steps taken to address them. Include the assessing clinician’s conclusion and rationale. When capacity is uncertain, document the uncertainty and escalation to the responsible clinician through the applicable consent pathway.

Make the discussion inspectable

Connect each material risk to the actual recommendation and clinical uncertainty. Record expected benefits, reasonable alternatives, the consequences of declining or delaying care, the person’s questions and the answers given. “All risks discussed” tells a later reader very little. ACEP’s 2025 guidance places these elements within the informed-refusal process.

A useful entry captures what the patient understood in their own words and identifies any remaining misunderstanding. It also records what changed after clarification. If the person changes their mind and accepts care, update the decision and task status; do not leave an earlier refusal as the only visible account.

U.S. and Ontario requirements have different scope

U.S. hospital emergency care — checked October 28, 2026. CMS Appendix V, interpreting 42 CFR §489.24(d)(3), addresses refusal of further examination or treatment within EMTALA obligations. It calls for recording the refused care, risks and benefits, reasons for refusal, and reasonable steps to obtain written informed refusal. When it is not secured, document the steps taken. Refusal of a proposed transfer has separate provisions in §489.24(d)(5). Apply these provisions within their hospital emergency-care scope. CMS State Operations Manual, Appendix V, pages 54–57

Ontario — checked October 28, 2026. CPSO’s Consent to Treatment policy applies Ontario’s Health Care Consent Act framework. Capacity involves understanding relevant information and appreciating reasonably foreseeable consequences. The consent dialogue includes the treatment, expected benefits, material risks, alternatives and consequences of not receiving it. CPSO also addresses communication barriers, voluntariness and substitute decision-making for an incapable patient. Use this framework and the local policy rather than importing a U.S. signature rule. CPSO: Consent to Treatment

For minors, involuntary psychiatric care, substitute decision-making and emergency exceptions, identify the applicable consent and legal-authority pathway. Keep its policy and escalation contact available to the team.

IF-03: voluntariness and an insurance-cost concern

U.S. insurance discussion — sources checked October 28, 2026. Do not tell a patient that leaving against medical advice automatically means insurance will refuse payment. The 2023 AAFP discussion identifies that claim as financial coercion and cites a single-center retrospective study that found no payment refusals attributable to AMA departure. Verify the individual patient’s coverage separately from the clinical recommendation.

Fictional example. These events show how a concern and a changed decision enter the record:

• 11:05 — concern: Morgan says, “I was told my insurance won’t pay if I leave.” The clinician records this as Morgan’s account; who made the statement has not been established. Morgan agrees to a private conversation and identifies the feared bill as the pressure affecting the decision.
• 11:10 — clarification: The clinician explains that AMA departure does not automatically establish insurance nonpayment and that Morgan’s individual coverage has not been verified. With Morgan’s agreement, a financial-counselor inquiry is requested. No answer has arrived. The clinician revisits the recommended continued assessment, its benefits, risks of leaving and available alternatives, separately from the coverage question.
• 11:15 — subsequent choice: Morgan says, “I understand that the bill is still uncertain. I want to stay to finish the assessment because the medical concern is still unresolved.” Morgan chooses continued assessment. The clinical team updates the earlier intention to leave and records the remaining assessment as pending.

Documentation excerpt: “11:15: Morgan reports feeling pressured by an insurance-nonpayment statement from an unidentified source. Private discussion accepted. Clarified that AMA departure alone does not establish nonpayment; individual coverage remains unverified. Financial-counselor inquiry requested with permission; response pending. Following a separate discussion of the clinical recommendation and alternatives, Morgan chooses to remain for continued assessment, explaining the unresolved medical concern as the reason. Earlier intention to leave updated. Further assessment remains outstanding.”

Record the concern, its source, the clarification and the actual response instead of inserting “no coercion” by default. Agreement with care does not itself establish capacity; retain the separate decision-specific assessment. Ontario teams can use CPSO’s voluntariness requirements to structure that part of their consent process.

IF-01: a worked informed-refusal record

Fictional example. IF-01 follows a clinician’s assessment, the patient’s decision, and the continuing care plan through the saved record.

Facts supplied before writing the note

Taylor, an adult, is in an emergency department with chest discomfort. At 14:10, the treating clinician recommends continued observation, repeat ECG and repeat blood testing because a serious heart problem has not been excluded. The initial blood sample is still awaiting a result. No examination findings or test values are supplied in this example.

Taylor says they need to collect their child. At 14:15, the clinician offers help contacting Taylor’s chosen support person to arrange collection. Taylor declines that assistance. The clinician explains that leaving could delay recognition and treatment of a heart attack, with serious harm or death, and explains the benefit of completing the evaluation. Taylor can remain for the recommended care and is told they may change their decision.

During the decision-specific assessment, Taylor explains that repeat tests may detect something the current evaluation has not yet identified. Taylor says, “Feeling better does not mean a heart problem has been ruled out for me.” Taylor compares remaining for assessment with leaving to collect their child and communicates the choice to leave. The fictional treating clinician documents that Taylor has capacity for this decision at 14:20, with those responses as the rationale.

At 14:25, Taylor continues to decline observation and repeat testing but accepts written instructions. The clinician reiterates the recommendation to stay. Taylor’s instructions invite a return at any time and specify emergency help for recurrent or worsening chest discomfort, breathlessness or fainting. Taylor explains back that those symptoms call for emergency help rather than waiting for a callback.

Taylor declines to sign at 14:30, saying, “I don’t want to sign paperwork.” The nurse hears that response and documents the signature request and refusal. Taylor leaves at 14:35. The treating clinician authenticates the note at 14:42; the later entry time does not replace the actual departure time.

The source packet also records an accepted handoff at 14:40: the incoming ED clinician takes responsibility for the initial result, with a 15:00 checkpoint. If it remains pending, they will contact the laboratory and reassess the response with the ED lead; an available actionable result requires earlier action. Taylor agrees to direct calls on a verified number, without detailed voicemail. The coordinator owns a follow-up request for the next morning; no appointment is booked.

Finished record using the worksheet fields

In IF-01, the team agrees on a 15:00 result-review checkpoint and a next-morning administrative task. The responsible clinician sets each checkpoint from the clinical situation. The record preserves two different unfinished states: a result awaiting review and a test that was never performed.

Practice: correct the overconfident draft

Taylor understands all risks, signed the AMA form and left after normal tests. Follow-up arranged. No further action needed.

Show the source-based corrections

• “All risks” becomes the specific discussion and Taylor’s recorded responses. Do not claim knowledge beyond what was assessed.
• “Signed” becomes signature declined at 14:30, with the witness’s actual role.
• “Normal tests” is removed. No values were supplied; the initial result is pending and repeat tests were not obtained.
• “Follow-up arranged” becomes a request with an owner, a checkpoint and an unbooked status.
• “No further action” is replaced by the accepted result-review handoff and open coordination task.

The corrected note should preserve the clinical uncertainty and continuing recommendation to complete the evaluation. Do not rewrite it as an approved routine discharge.

When the form is unsigned or the discussion never happened

An unsigned form and an undocumented discussion are different problems. If a person declines to sign, record the actual conversation, the request for signature and the response. A witness can describe what they observed; their presence should not be converted into evidence that they performed the clinical assessment. CMS’s applicable refusal provisions address steps taken when written refusal is not obtained. CMS Appendix V

If a person leaves before assessment or before the discussion can occur, preserve the sequence instead of filling the form retrospectively as though they participated. For a hypothetical IF-02 entry: “Last seen in the waiting area at 18:05. Called at 18:15 and 18:25 without response. Treating clinician informed at 18:27. Refusal discussion and capacity assessment not completed.” Record subsequent contact attempts and actions only if they actually occur. Local policy determines the appropriate departure classification and response.

Separate a late entry from an event time. If a nurse observed departure but the clinician learned of it later, attribute the source. When additional information changes the account, preserve the original and add a dated correction using the record’s amendment process. The clinical note examples show how source attribution prevents a secondhand report from becoming a direct observation.

Departure does not close pending work

A discharge status does not prove that a result was reviewed, a referral accepted or the patient reached. AHRQ’s 2005 PSNet teaching commentary emphasizes discharge instructions, follow-up and communication with the continuing care team. Set review timing for the individual encounter and record who will act. AHRQ: Discharge Against Medical Advice

For each unfinished item, keep the action, owner, checkpoint, backup and actual outcome visible. In IF-01, the incoming clinician’s acceptance at 14:40 is evidence of transferred responsibility. Merely putting a name into a task field would not demonstrate that acceptance.

When contact fails, record the route used and outcome, then the next action under the agreed plan. “Message sent” should not become “patient informed.” Confirm the patient’s contact preferences and use the approved channel; avoid sensitive details in a message when authorization has not been established. The PHI guide explains why information in communications needs the same attention as the note itself.

Use the referral-letter workflow to distinguish requested, sent, received and accepted follow-up. A discharge summary can carry the clinical course and continuing plan, while the refusal record preserves the specific decision and discussion. Link the records rather than copying conflicting versions across them.

Quality checklist for the saved record

Review the actual saved destination, not only the draft on screen. This checklist is an original editorial control for comparing the worksheet, note, instructions and task list:

1. Specificity: Can the next clinician identify the precise care declined and why it was recommended?
2. Evidence: Are capacity findings and the conclusion attributed to the assessing clinician and decision time?
3. Discussion: Are material risks, benefits, alternatives and the patient’s responses visible?
4. Partial acceptance: Does the record distinguish declined care from care accepted and provided?
5. Signature accuracy: Does the structured status match signed, declined or unavailable?
6. Chronology: Are discussion, departure and entry times distinguishable?
7. Unfinished care: Are pending results separate from tests not obtained?
8. Responsibility: Is there evidence of accepted ownership, timing and a backup for open work?
9. Communication: Do instructions and contact records show what was actually delivered or received?
10. Consistency: Do later corrections update affected tasks and recipients as well as the narrative?

An AI drafting workflow may help organize supplied material, but the responsible clinician must review the final record. Keep the source account available while checking the draft. The decisive question is whether the saved note accurately represents this encounter—including what remains unknown and what still needs to happen.