Left AMA

[SeekerOfTheTree]

Question for all of you. A patient comes in and doesn't want to be seen. Not drun or suicidal, none of that. Nurses tell you that and you go okay. They document you as giving the thumbs up for AMA eventhough you never saw the person. You guys ever seen this? Would you write a whole chart note? How do you guys handle this?

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[EMhawkeye]

They need to be educated on the difference between ama and left without being seen. If patient leaves before provider sees them, it’s a lwbs not an ama.

 

[comp1]

It literally can't be against medical advice. No advice was given.

 

[NYEMMED]

It’s not AMA it’s LWBS.

LWBS may not protect you from liability, nor an EMTALA violation.

I usually try to see all of these, so my MSE and AMA talk and have them sign.
I figure I’d probably be more protected from a EMTALA/ liability perspective if I can say “I did everything I could to make them stay, and I explained it all”

 

[cyanide12345678]

Question for all of you. A patient comes in and doesn't want to be seen. Not drun or suicidal, none of that. Nurses tell you that and you go okay. They document you as giving the thumbs up for AMA eventhough you never saw the person. You guys ever seen this? Would you write a whole chart note? How do you guys handle this?

Left without being seen. Not ama.

 

[southerndoc]

There are actually legal definitions defined by CMS regarding this:

LWBS: has not received a MSE (whatever your facility defines as capable of providing one - can be a nurse if your facility allows it)
Eloped: a patient without capacity leaves without telling anyone (i.e., demented patient or on involuntary psych hold)
AMA: patients who leave after screening regardless if you had a discussion with them regarding risks of leaving

I used to think if they left without telling anyone while workup was in progress it was an elopement. Both health law and the CMS specifically define elopement as leaving without capacity to make decisions.

Regarding the OP's question: it's poor form to say someone "allowed" a person to leave AMA. I hate it when paramedics call and say "is it ok if they sign AMA?" It's like you're giving them a blessing to not be treated. It's a huge pet peeve of mine.

 

[BoardingDoc]

I used to think if they left without telling anyone while workup was in progress it was an elopement. Both health law and the CMS specifically define elopement as leaving without capacity to make decisions.

What?! I've literally been documenting "eloped" for any patient that has been seen, but then up and leaves without telling someone. So has every ED doc I know.

What the heck is that scenario called then?

 

[TooMuchResearch]

What?! I've literally been documenting "eloped" for any patient that has been seen, but then up and leaves without telling someone. So has every ED doc I know.

What the heck is that scenario called then?

Left without telling anyone?
Your system may have an actual disposition for this in the EMR.

 

[BoardingDoc]

Left without telling anyone?
Your system may have an actual disposition for this in the EMR

I thought it did with "eloped." There is nothing else that fits the bill. Admitted, discharged, eloped, lwbs, transfer, expired, ama, signed out, observation.

 

[WhatJobDoIPick]

Question for all of you. A patient comes in and doesn't want to be seen. Not drun or suicidal, none of that. Nurses tell you that and you go okay. They document you as giving the thumbs up for AMA eventhough you never saw the person. You guys ever seen this? Would you write a whole chart note? How do you guys handle this?

You document "patient eloped from the ER prior to my assessment".

Been doing this for ten years and hasn't steered me wrong.

Emtala guarantees a medical screening exam. It doesn't guarantee it on your terms, precisely when you want it, by a person of whatever color / religion / biological sex you desire or whatever other nonsense specifications patients have.

You want to leave? You're an adult, you are allowed to leave.

 

[retro]

I'm sure it's hospital dependent, but our ED has a disposition called 'left during evaluation,' which means a person with full capacity left without telling anyone before dispo is made. This differs from AMA, because you didn't have a chance to go over the medical advice / risk and benefit spiel with the patient before they left. In our hospital, it becomes a big problem if someone 'elops' because the patient not only lacks capacity, but it's the hospital system (1:1 observation, hospital police etc) that failed to keep these folks from running away. The admins will get in trouble for this.

 

[southerndoc]

What?! I've literally been documenting "eloped" for any patient that has been seen, but then up and leaves without telling someone. So has every ED doc I know.

What the heck is that scenario called then?

Yeah, so did I. It was only within the past few months that I learned that CMS has specific language detailing this (as do the healthcare attorneys).

I loved putting "eloped from emergency department" as a diagnosis in Epic. This is what caught the attention of some health system attorneys when they were running a report.

CMS also recognizes "left subsequent to being seen" in addition to LWBS.

"Elopement is defined as a patient who leaves the hospital when doing so may present an imminent threat to the patient's health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave. Elopement does not include events involving competent adults with decision-making capacity who leave against medical advice or voluntarily leave without being seen. "

EDIT: Meant to post this link:

Elopement | PSNet

Elopement is when a patient leaves a healthcare facility against medical advice, when doing so poses an imminent threat to the patient's health or safety. In many cases, the decreased mental capacity or intermittent mental status.

psnet.ahrq.gov

 

[xaelia]

CMS also recognizes "left subsequent to being seen" in addition to LWBS.

We call it "Left before treatment complete"

Shifts a bit of the negative connotation onto the patient – "we tried to treat them!"

Caveat: New Zealand

 

[Apollyon]

We call it "Left before treatment complete"

Shifts a bit of the negative connotation onto the patient – "we tried to treat them!"

Caveat: New Zealand

LBTC was an option with WellSoft, which I used in residency.

 

[AlmostAnMD]

You are responsible for anyone that physically enters your department. A colleague lost a suit where someone checked into lobby, sat down, and died 5 minutes later. Didn't seem ill enough to bring back acutely, just had abdominal pain.

All these LWBS, AMA things are just for show. You are a cog in the liability machine and without god-tier documentation neither dispo status will automatically save you.

Another reason I'm getting out. Last month of EM baby!!

 

[southerndoc]

You are responsible for anyone that physically enters your department. A colleague lost a suit where someone checked into lobby, sat down, and died 5 minutes later. Didn't seem ill enough to bring back acutely, just had abdominal pain.

All these LWBS, AMA things are just for show. You are a cog in the liability machine and without god-tier documentation neither dispo status will automatically save you.

Another reason I'm getting out. Last month of EM baby!!

Somebody's defense counsel was extremely poor if they lost litigation for someone they had not yet evaluated and established care. There have been quite a few cases filed against physicians for patients who have died in the waiting room. This is the first I've heard of the physician being held accountable for a patient they were not aware of existed in the department. Mind DM'ing me the details so I can research further?

 

[dozitgetchahi]

When I saw “left AMA”, I was assuming that the OP left the American Medical Association. I was like “oh, I did that years ago”.

 

[SeekerOfTheTree]

Thanks for all the input. To add further to this if you go to approach the patient and introduce yourself and they state they don't want to be seen and want to leave, how do you deal with that? If I write a note that gets billed is that fraud then? Do I write a note because the patient refused care and now I am billing a level 2 or 3 for screening exam? This seems to happen every now and then when someone beligerent is brought in and doesn't want to answer questions other than saying things like I don't want to be seen, don't touch me, etc. What do you guys do for these scenarios? In certeain states AMA actually does have a legal protection status and if you leave AMA you can't be sued for the outcome (I looked this up for a few states).

 

[SeekerOfTheTree]

Getting sued for someone that no one other than triage saw is extreme. Where the heck was this?

 

[SmokingMonkey]

Thanks for all the input. To add further to this if you go to approach the patient and introduce yourself and they state they don't want to be seen and want to leave, how do you deal with that? If I write a note that gets billed is that fraud then? Do I write a note because the patient refused care and now I am billing a level 2 or 3 for screening exam? This seems to happen every now and then when someone beligerent is brought in and doesn't want to answer questions other than saying things like I don't want to be seen, don't touch me, etc. What do you guys do for these scenarios? In certeain states AMA actually does have a legal protection status and if you leave AMA you can't be sued for the outcome (I looked this up for a few states).

I've never worked in a state that provided any legal protection for AMA, especially when the AMA process is a nurse saying "sign this form and you can leave" with no actual discussion (which I've seen happen). So I always do a screening exam (to whatever level the patient allows), document well, and try to decrease my liability that way. And they also get a bill, because I provided a service (the medical screening exam).

I did learn today I've been misapplying elopement for years...

 

[SeekerOfTheTree]

I've never worked in a state that provided any legal protection for AMA, especially when the AMA process is a nurse saying "sign this form and you can leave" with no actual discussion (which I've seen happen). So I always do a screening exam (to whatever level the patient allows), document well, and try to decrease my liability that way. And they also get a bill, because I provided a service (the medical screening exam).

I did learn today I've been misapplying elopement for years...

Sorry I didn't mean the term AMA but refusal of care itself.

 

[johhnybgood]

You are responsible for anyone that physically enters your department. A colleague lost a suit where someone checked into lobby, sat down, and died 5 minutes later. Didn't seem ill enough to bring back acutely, just had abdominal pain.

All these LWBS, AMA things are just for show. You are a cog in the liability machine and without god-tier documentation neither dispo status will automatically save you.

Another reason I'm getting out. Last month of EM baby!!

What are you moving into from EM?

 

[deleted1140701]

You are responsible for anyone that physically enters your department. A colleague lost a suit where someone checked into lobby, sat down, and died 5 minutes later. Didn't seem ill enough to bring back acutely, just had abdominal pain.

All these LWBS, AMA things are just for show. You are a cog in the liability machine and without god-tier documentation neither dispo status will automatically save you.

Another reason I'm getting out. Last month of EM baby!!

What kind of BS is that? If they truly died 5 minutes later looking stable at the time, bringing them back wouldn't have changed much. Especially given that it sounds like some sort of AAA rupture.

Medical malpractice lawyers are absolute scum. I hope I never meet one, especially in a social setting because I will rip them a new one and likely regret it later.

 

[Apollyon]

What kind of BS is that? If they truly died 5 minutes later looking stable at the time, bringing them back wouldn't have changed much. Especially given that it sounds like some sort of AAA rupture.

Medical malpractice lawyers are absolute scum. I hope I never meet one, especially in a social setting because I will rip them a new one and likely regret it later.

I remember about 15 years ago, I was getting gas in my BMW, and there was another guy there in a BMW. He was in a suit. I asked what he did. He said he was med mal defense. He said that he had been med mal, but got to the point he couldn't look himself in the eye. He said he had to get out before he went nuts.

 

[southerndoc]

Medical malpractice lawyers are absolute scum. I hope I never meet one, especially in a social setting because I will rip them a new one and likely regret it later.

I used to date one. LOL Talk about sleeping with the enemy!

 

[thegenius]

Question for all of you. A patient comes in and doesn't want to be seen. Not drun or suicidal, none of that. Nurses tell you that and you go okay. They document you as giving the thumbs up for AMA eventhough you never saw the person. You guys ever seen this? Would you write a whole chart note? How do you guys handle this?

You tell the truth in the chart. Don't lie. Say you never saw the patient, you never authorized an AMA. I was told "blah blah blah". Etc.
It's OK to write a chart saying you never saw the patient. I don't routinely do it but occasionally I'm forced to.

This isn't an EMTALA problem either. If a patient doesn't want to be seen and doesn't want a medical screening examination, you have no duty to take care of them. Of course it's a bit of a problem if they have a knife sticking out of their neck, but that doesn't happen all that often.

 

[thegenius]

It’s not AMA it’s LWBS.

LWBS may not protect you from liability, nor an EMTALA violation.

I usually try to see all of these, so my MSE and AMA talk and have them sign.
I figure I’d probably be more protected from a EMTALA/ liability perspective if I can say “I did everything I could to make them stay, and I explained it all”

I agree that if a patient LWBS it depends on why. If they LWBS because they had RLQ pain and nobody saw them for 8 hours, and they left to go to another hospital and was dx with ruptured appy, then you are in trouble both with EMTALA and perhaps even with general malpractice tort. But if you see someone and they just wanna leave, and you give them an opportunity to help them and they decided they don't want a medical screening exam, then you are done. No duty to determine if they have an EMC. As long as they appear to be OK. They could come in with their entire face and scalp torn off...and not want to be seen. You can't let that go.

 

[thegenius]

I thought it did with "eloped." There is nothing else that fits the bill. Admitted, discharged, eloped, lwbs, transfer, expired, ama, signed out, observation.

I guess it's then AMA. There should be qualifiers with it though
AMA - w/ discussion
AMA - w/ discussion w/ signed paperwork
AMA - w/o discussion

 

[southerndoc]

I guess it's then AMA. There should be qualifiers with it though
AMA - w/ discussion
AMA - w/ discussion w/ signed paperwork
AMA - w/o discussion

AMA - doctor was pissed off and didn't want to write any more narcotics LOL

 

[thegenius]

Thanks for all the input. To add further to this if you go to approach the patient and introduce yourself and they state they don't want to be seen and want to leave, how do you deal with that? If I write a note that gets billed is that fraud then? Do I write a note because the patient refused care and now I am billing a level 2 or 3 for screening exam? This seems to happen every now and then when someone beligerent is brought in and doesn't want to answer questions other than saying things like I don't want to be seen, don't touch me, etc. What do you guys do for these scenarios? In certeain states AMA actually does have a legal protection status and if you leave AMA you can't be sued for the outcome (I looked this up for a few states).

I think you are reading too much into this. Again as I wrote prior, I think you write the truth.
1) if you never saw a patient, I usually don't put in a note. Occasionally I need to though for weird reasons and I write something to the effect of "Pt came to the ED with a chief complaint of 'x'. I never saw nor examined the patient. I was told by the RN he left the ER." That's the truth. I have no idea how this would be billed, nor do I care.

2) if you saw the patient, and then the patient left, you write what happened. I won't spell it out as you can imagine from my example above how it would go.

3) if you approach the patient and they want to leave....I'll ask a few questions. "Why did you come?" "Do you have a medical complaint? Something you want me to help you with?" Just try to get a sense of their cognition. As long as they are not bat-schit crazy. and don't have an obvious medical emergency, I let them go.

Of course there are fringe cases and you just have to deal with them. Some common ones are

- PD brings in someone arrested for medical clearance. For whatever reason. The arrested person doesn't want a medical exam. As long as there is nothing obvious going on (like there is a knife sticking out of their neck), if the person doesn't want an MSE and there is no obvious emergency, I simply tell PD that it's the patient right not to have a MSE so I can't "medically clear" them. I'll be discharging them back to PD. (Invariably these people are usually cited and released back to society. They are not taken to jail. Sucks.)

- Family brings in grandpa who is acting weird. He doesn't want to be in the ER. He is acting, more or less, normal in front of you and family. I work with the family as much as possible in these cases, but tell them explicity that I can't force an MSE on the patient if they can make their own medical decisions. They might quip back "but he can't because he's confused" but that is usually easy to squash because you just talk to the patient and make everybody realize that he does have capacity. But usually just talk to the patient:
-- your family is concerned about you, what do you think about that?
-- what are your symptoms?
-- we could do a little or a lot: physical exam, vital signs, maybe blood work, maybe a few xrays, or maybe an ultrasound or CT Head
-- won't force anything on you.

We have all had these kinds of patients and usually the encounter goes well.

- Pt comes in with a clear medical emergency, they are close to dying on you, and they want to leave. I had a UGIB once from an advanced cirrhotic. vomiting and schitting blood. Vitals were terrible. He really didn't want the ambulance to take him to my hospital, but he was there. Refused everything. He looked awful. Treatment was delayed by over an hour as his wife came back and tried to convince him to stay, and he didn't. All the stops were pulled out.
"You are welcome to leave under your own power, but I doubt you have the strength to walk out."
"The moment you go home and collapse, and 911 comes, they will bring you right back here because we are the closest hospital and you are super sick."
"There is no way we can send you to another hospital right now due to the law, and you are super sick."
We spoke for over an hour. He finally vomited like 4 cups of blood and became very tired and encephalopathic, and only at that point did he say "well I don't think I have a choice now do I." He soon after almost passed out. Hg was 3. massive transfusion ensued, he was admitted and spent a few weeks in the ICU.


These are the toughest. You do your best

 

[xaelia]

He finally vomited like 4 cups of blood and became very tired and encephalopathic, and only at that point did he say "well I don't think I have a choice now do I." He soon after almost passed out. Hg was 3. massive transfusion ensued, he was admitted and spent a few weeks in the ICU.

Hate to say it, but he probably died of sepsis or recurrent UGIB not long after ....

These stories of "pulling out all the stops" ... the prevailing culture, I know, I know, but, still ... I digress.

There may be too much hair-splitting in terminology above, excepting for the actual "what gets reported as the disposition to CMS". Everything else – as previously noted, just truthfully document sincere efforts to provide appropriate care and put it to bed.

 

[WhatJobDoIPick]

I dunno man I think it's weird this thread has persisted this long. It's pretty straightforward. Why is there all this stress about this? If they wanna leave, they leave. If you saw them before it happened and you have an AMA discussion, it's AMA. If if was before you saw them or they just walk out it's elope/lwbs/whatever you wanna call it. I've worked in many many ERs in many states (locums) and have literally never heard the slightest bit of a problem about any of this.

 

[JacobMcCandles]

Just be reasonable and write what happened in the note if you saw them. If I didn’t see them or I wasn’t even aware of them then I don’t put in a note because that doesn’t make sense to me. I’ll let those chips fall where they may.

 

[TrailRun]

I don't think you have a doctor-patient relationship with them if you haven't seen them. Of course anyone can sue for any reason at any time, doesn't mean they'll be successful. But the issue I forecast is that RN writes "informed Dr. Smith patient left without being seen/eloped, etc, MD aware." I guess a lawyer could argue that you hadn't assessed capacity. But just because someone checks in to an ER doesn't mean they don't have the right to leave whenever they want also

 

[DocEspana]

Pt ducks out of the waiting room and didnt even visit a triage nurse and have any medical professional evaluate them: LWBS and no note from me.

Pt ducks out of the waiting room but did see a triage nurse who got a decently detailed story for me: LWBS but I write a barebones note stating the nurse got a triage evaluation and told me this was the complaint but I couldn't evaluate them because they left for *reasons* (helps for keeping the records of the visits accurate and dodging them bitching about the hospital since you have a contemporaneous record of what happened as well)

Patient is seen by me and just ****ing skedaddles without telling anyone: elopement and gets a full billable note from me saying they pulled a houdini

Patient is seen by me and tells the nurses he wants to GTFO and they get him to sign a form but I find out about it afterwards: AMA and full note, but I specifically document that the AMA conversation was had with nursing and that I was not made aware until after patient had evacuated the premises

Patient is seen by me and tells me to his face "yo doc. I'm out" and I got to tell them its a medical/legally dumb idea: AMA and full note as well as my summary of risks.

 

[TooMuchResearch]

You are responsible for anyone that physically enters your department. A colleague lost a suit where someone checked into lobby, sat down, and died 5 minutes later. Didn't seem ill enough to bring back acutely, just had abdominal pain.

All these LWBS, AMA things are just for show. You are a cog in the liability machine and without god-tier documentation neither dispo status will automatically save you.

Another reason I'm getting out. Last month of EM baby!!

Alternative:
**** tier documentation. I dislike opening someone's note and it's a useless several page mdm.

 

[AlmostAnMD]

Alternative:
**** tier documentation. I dislike opening someone's note and it's a useless several page mdm.

Oh, absolutely. That has very much contributed to my burnout. Especially at my high volume shop. I just document what is needed in a medical chart to convey what medically happened. My MDM is only more than a sentence or two if it's a complex case. Otherwise I just can't keep myself up at night with what if's. Too many docs in our group losing years of life stressing hard about MDM. Staying an hour + late a day to chart. Residency nonsense.

To whomever asked, I'll post about my new career later. Out of EM. Too much risk. Not enough reward. And money isn't all there is to life.

 

[Rekt]

What a crazy thread with a bunch of nonsense posted with no evidence. You guys must work in magical hospitals. We have double digit LWBS from the lobby every day. Usually an ama myself every shift. Sometimes people “elope” by just walking out. No one cares about any of this. You’d have to be incredibly dumb to put a note on a waiting room patient. I don’t even click their charts. If a patient has capacity and wants to leave then it’s on them. I’ll take that to court all day long.

 

[wareagle726]

I used to really worry about this. I don't as much now, especially in the post-covid boarding nightmare we're all it. I'll give my summary thoughts:

-If someone leaves before my disposition and I have no knowledge I document LBEC(left before evaluation complete). I was made aware of what SouthernDoc was referring to a few years ago. Elopement from a legal standpoint is really a psych term or pertaining to those who lack clinical capacity.

-When the nurses come up and say "the patient left AMA" I ask them what medical advice was given and they usually give me a blank stare. I document that I was not made aware that the patient was leaving so I couldn't properly advise them or give further instruction. I also look at the results of any diagnostics and remark on them AND in the very rare situation where I am actually concerned try and call the patient/family to try and get them to come back(only happened a few times)

-How the heck are ya'll keeping up with all the people in the lobby? I get it if there's 3 people out there and you can keep up with all the triage notes but when there are 30 people in the WR and more constantly pouring in I sure as hell don't have a running tab on who suddenly vanished from the board and LWBS. I never write notes on these people. If someone seems sick(vitals are bad from triage or obvious emergency) sure I keep an eye on it and try and get them back. Outside of that I don't see how I could possibly be asked to keep up with all of them.