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.
護理紀錄
1410：個案在間歇性胸部不適評估後意識清楚，並說：「我現在想回家。」護理師記錄個案在回覆示教後，用自己的話解釋了選擇和可能的後果。紀錄接著指出雖然個案有決策能力，但仍要求成年子女簽署拒絕書。1418時，醫師解釋尚未排除心肌損傷，並建議重複檢查。個案聆聽，且護理師以可理解的用語說明了在系列檢查完成前離開的具體風險。團隊提供較早的門診預約，且個案接受了次日門診的書面替代追蹤計畫。1425時，一名工作人員說在建議的檢查完成前，將扣留個案的衣物。個案保持平靜，並重複想離開的意願。離開前，護理師移除靜脈導管，並確認穿刺部位完整無出血。出院資料包含個案收到需要立即緊急返院的書面症狀和指示。1432時，紀錄顯示紀錄僅寫「違反醫囑出院」，而無風險、替代方案或個案反應。護理師也通知醫師有能力的個案持續拒絕照護，並記錄聯繫內容。另一名工作人員表示即使沒有緊急留置或法律限制，保全也應阻擋出口。護理長暫停流程，並與團隊檢視個案權利的應對方式。