Nurses' Notes
1410: The client is alert after evaluation for intermittent chest discomfort and says, “I want to go home now.” The nurse documents that the client explains the choice and possible consequences in personal words after teach-back. The record then states that the adult child is asked to sign the refusal although the client has capacity. At 1418, the provider explains that myocardial injury has not been excluded and recommends repeat testing. The client listens and the nurse describes the specific risk of leaving before serial tests are complete in understandable words. The team offers an earlier clinic appointment and the client accepts a written alternative follow-up plan for the next-day clinic. At 1425, a staff member says that the client's clothing will be kept until the recommended testing is finished. The client remains calm and repeats the wish to leave. Before departure, the nurse removes the intravenous catheter and confirms the site is intact without bleeding. The discharge packet includes that the client receives written symptoms and instructions that require immediate emergency return. At 1432, the record shows that the note contains only “left AMA” without the risks, alternatives, or client response. The nurse also notifies the provider that the capable client continues to decline care and records the contact. A second staff member states that security should block the exit even though no emergency hold or legal restriction exists. The charge nurse pauses the process and reviews the client-rights response with the team.
Nurses' Notes
1410: The client is alert after evaluation for intermittent chest discomfort and says, “I want to go home now.” The nurse documents that the client explains the choice and possible consequences in personal words after teach-back. The record then states that the adult child is asked to sign the refusal although the client has capacity. At 1418, the provider explains that myocardial injury has not been excluded and recommends repeat testing. The client listens and the nurse describes the specific risk of leaving before serial tests are complete in understandable words. The team offers an earlier clinic appointment and the client accepts a written alternative follow-up plan for the next-day clinic. At 1425, a staff member says that the client's clothing will be kept until the recommended testing is finished. The client remains calm and repeats the wish to leave. Before departure, the nurse removes the intravenous catheter and confirms the site is intact without bleeding. The discharge packet includes that the client receives written symptoms and instructions that require immediate emergency return. At 1432, the record shows that the note contains only “left AMA” without the risks, alternatives, or client response. The nurse also notifies the provider that the capable client continues to decline care and records the contact. A second staff member states that security should block the exit even though no emergency hold or legal restriction exists. The charge nurse pauses the process and reviews the client-rights response with the team.