AGAINST MEDICAL ADVICE FORM
Refusal of recommended care, with the clinician's note

Patient: [Full name]
Date of birth: [Date]
Record number: [Number]
Date and time: [Date, and time of the discussion]
Where: [Emergency department, ward, clinic, or other setting]
Clinician: [Name, credentials, role]
Also present: [Nurse, family or friend at the patient's request, interpreter, or none]

PART 1: THE PATIENT'S FORM

My condition: [What the care team thinks is wrong, or what still needs to be ruled out, in plain words]
What my care team recommends: [Staying in hospital, a test, a treatment, a procedure, or waiting for a result]
Why they recommend it: [What it should find, treat, or prevent]

What I am declining: [All further care, or the specific part declined]
What I still accept: [A dose before leaving, prescriptions, a follow-up visit, or nothing]

What could happen if I decline: [Each risk in plain words, including serious illness, permanent disability, or death where that is true]

Other options I was offered: [Each option, such as a shorter stay, a different treatment, or help with my reason for leaving, and my answer]

I have been told about my condition, the care recommended, what could happen if I decline it, and the other options. My questions have been answered. I am choosing to [leave the hospital, or decline the care above] against the advice of my care team. I know I can change my mind and come back at any time, and I will be cared for when I do.

Patient: [Signature, printed name, date and time]
If the patient declines to sign: [The patient's words, the time, and who heard them]
Clinician: [Signature, printed name, role, date and time]
Witness: [Signature, printed name, role, date and time, where your organization's policy asks for one]
Interpreter: [Name or ID, language, and in person, phone, or video, or not used]

PART 2: THE CLINICIAN'S NOTE

CLINICAL PICTURE
Presentation and findings: [Key history, exam, and results that make the recommendation urgent]
Working diagnosis: [Diagnosis, or what is still being ruled out]
Treatment so far: [Tests done, treatments with dose and time, and results still pending]

RECOMMENDATION AND DECISION
Recommended: [The care recommended, and what it should achieve]
Declined: [Exactly what the patient declines, and when they said so]
Accepted: [What the patient still agrees to]

CAPACITY FOR THIS DECISION
Checked for: [Alcohol or drugs, glucose, oxygen, pain, delirium, head injury, hearing, and language]
Understands: [The patient's own account of the condition and the recommendation]
Appreciates: [The patient's words showing the risks apply to them]
Reasons: [How the patient weighed staying against leaving, in their words]
Choice: [The decision, and whether it stayed the same over time and with different staff]
Finding: [Has capacity for this decision, or the concern, who assessed further, and the result]

THE DISCUSSION
Risks explained: [Each risk, in the words used, most serious first]
Benefits of staying: [What the recommended care offers, in the words used]
Patient's reasons: [In the patient's words]
Alternatives offered: [Each alternative, and the patient's answer]
Questions asked: [The patient's questions, and the answers given]
Others involved: [Senior clinician, consultant, social worker, or family with the patient's agreement, or none]

CARE STILL PROVIDED
Before leaving: [Doses given with times, and IV lines removed]
Prescriptions: [Each medicine, dose, how often, and for how long]
Follow-up: [With whom, when, whether booked, and who calls if the patient doesn't come]
Results pending: [Each result, who will check it, and the confirmed phone number]
Return advice: [The signs to come back for or call 911, and what the patient said back]
Invitation to return: [Told they can come back at any time, and the words used]
Copies given: [This form, discharge instructions, and prescriptions]

DEPARTURE
Left at: [Time, how, and with whom]
Condition on leaving: [Symptoms and last vital signs]
Told: [Admitting team, consultant, primary care clinician, or none]

Signed: [Clinician name, credentials, date and time of this entry]