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Statement of Patient Leaving Against Medical Advice


Date of Last Review 5/19/08
SME: Associate
Director of Nursing

Date of Last Review: October 10,2011

SME: Chief Nursing Officer

SME: changed to: Medical Director-October 10,2011

Statement of Patient Leaving Against Medical Advice form is used for patients who want to be discharged even though they have been told they are in danger of adverse medical effects (mental or physical) by being discharged.

Discharge process

This table describes what staff does when the patient is discharged against medical advice:


Person Responsible




Obtains a completed, signed Request for Release letter from the patient/parent/guardian, or documents the refusal to sign with two witnesses


The attending physician

No longer than 4 hours after completion of the Request for Release does the following:

Discusses the discharge request with the patient

Makes and writes the following determination in the patient's chart:

The patient is not committable

The patient is in danger of adverse mental or physical effects by failing to complete treatment



Performs the following:

Stamps the Statement of Patient Leaving Against Medical Advice form with the patient's stamp

Completes the blanks

Has the patient or guardian sign, as appropriate, along with a witness


Discharge staff

Discharges the patient


Head nurse or designee

Completes and processes a Patient Care Variance report

Aftercare prescription

The physician provides the patient with appropriate prescriptions for the interim between discharge and the first aftercare appointment or two weeks.

Authorized release return failure

A patient is discharged against medical advice if s/he does not return from an authorized release within 48 hours of the time limit on the release unless the physician extends that time. If the patient does not return, the attending physician notes in the medical record that the patient was discharged against medical advice.


Statement of Patient Leaving Against Medical Advice

Request for Release

Patient Care Variance Report form

Related standards

Joint Commission: Provision of Care, Treatment, and Services

Center of Medicare/Medicaid Conditions of Participation for Psychiatric Hospitals

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Harris County Psychiatric Center University of Texas Health Science Center