shift is wild

When something goes wrong with a patient or a med

When the patient walks out before discharge

Five questions the chart has to answer once the bed is empty, and the one-liner that answers none of them.

10 min read built on 6 full opinions updated 2026-10-02

Written by a med-surg RN, ten years, day shift. Why there is no name on it

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Sometimes the patient tells you they're leaving. Sometimes you walk in for 0400 vitals and find an empty bed with the IV tubing hanging off the pole. Either way, the chart has to answer five questions later: when you last saw the patient, what happened to the lines, which risks you explained, who you called, and when you found out they were gone.

The short version

  • Write when you last saw the patient, and how. Say something like direct observation at 0200 hourly rounding: asleep, respirations even. Don't write last seen earlier in shift.
  • Write what happened to every line. Either the catheter came out with the tip intact, or the patient left with the IV in. If it stayed in, write what you did about it.
  • Name the risks you explained, in plain words. Risks explained on its own tells the next reader nothing.
  • Give every notification a time and a name. That means provider, charge nurse, security, emergency contact and police, per your facility's policy. Write what you told each one, not just that you called.
  • Don't mix up AMA and elopement. AMA means there was a conversation, and maybe a signed form. Elopement means you found an empty room. Chart the one that actually happened.

What to write instead

How it's usually written How it reads better
Pt left AMA. MD aware.2015 Pt states he wants to leave now, plans to walk to a friend's house approx. 1 mile away. Dressed in pants, button-down shirt, slippers; outside temp per weather service 10°F with snow. Dr. [NAME] paged 2018, informed of patient's request, clothing, plan to walk, last hydromorphone 1 mg IV at 1930, and day-shift note re: statements about not wanting to live. Dr. [NAME] to bedside 2030.
Pt eloped.0200 Pt observed in bed during hourly rounding, eyes closed, resp even and unlabored. 0310 Pt not in room, not in bathroom or hallway. Personal belongings and coat gone. Charge RN [NAME] notified 0312; unit and lobby search per policy 0312–0325, pt not found. Security notified 0315.
Risks explained, pt verbalized understanding.Explained to pt that leaving before IV antibiotics are complete risks the infection spreading to blood, which can cause low BP, organ damage, or death. Pt repeated back in own words that the infection could get into his blood and that he should go to an ER if he gets fever, chills, or confusion.
IV d/c'd.Pt requested PIV removal before leaving. 20g PIV R forearm removed 2040, catheter tip intact, site without redness or swelling, pressure held 2 min, dressing applied.
Pt left with IV.Pt declined PIV removal and left the unit 2045 with 20g PIV L hand in place. Explained risks of infection, bleeding, and air entering the vein; advised to return or go to nearest ER for removal. Dr. [NAME], charge RN [NAME], and security notified 2047. Emergency contact [NAME] called 2050, informed PIV in place.
Pt A&Ox4, has capacity.Pt states full name, date of birth, hospital name, today's date, and reason for admission. Able to explain in own words what he is refusing and what could happen if he leaves. Dr. [NAME] at bedside 2030, assessed capacity.
Pt refused to sign AMA form.AMA form offered 2035. Pt declined to sign, stated in own words that he will not sign anything. Risk discussion as above was completed before pt left. Witness: [NAME], RN.

Copy this

Chart note: patient leaving against medical advice

``` [DATE] [TIME] Pt states intent to leave the hospital. Pt's stated reason, in own words: [PATIENT'S REASON]. Pt's stated plan: going to [DESTINATION] by [TRANSPORT: car with NAME / walking / taxi / bus]. Pt dressed in [CLOTHING]. Weather at time of departure: [WEATHER, if relevant].

Assessment at [TIME]: VS T [ ] HR [ ] BP [ ] RR [ ] SpO2 [ ] Pain [ /10]. Mental status: pt states [NAME / DOB / LOCATION / DATE / REASON FOR ADMISSION]. [SPEECH, BEHAVIOR, AFFECT]. Last sedating / opioid medication: [DRUG, DOSE, ROUTE] at [TIME]. Relevant info from chart or prior shift: [e.g., statements about self-harm, fall risk, withdrawal risk, or NONE].

Treatment pt is declining: [e.g., remaining IV antibiotic doses, CT scan, cardiology consult, admission]. Risks explained to pt by [NAME, ROLE] at [TIME]: [RISK 1], [RISK 2], [RISK 3], including the possibility of [death / permanent harm, if applicable]. Pt repeated back in own words: [WHAT PT SAID BACK]. Alternatives offered: [e.g., stay until morning, stay for one more dose, family pickup, return precautions].

Notifications: [TIME] Dr. [NAME] notified by [phone / in person]. Told: [FACTS GIVEN]. Response: [ORDERS OR PLAN]. [TIME] Charge RN [NAME] notified. [TIME] [Others per policy: security, house supervisor, emergency contact NAME].

Lines and devices: [DEVICE, SIZE, SITE] removed at [TIME], catheter tip intact, site [DESCRIPTION]. OR: Pt declined removal of [DEVICE, SIZE, SITE]. Explained [RISKS]. Advised [PLAN]. Notified [NAMES] at [TIME]. Other devices: [telemetry box returned / drains / O2 / NONE].

AMA form: [signed by pt at TIME, witnessed by NAME] OR [offered at TIME, pt declined to sign]. Discharge instructions / return precautions given: [WHAT, verbal and/or written]. Prescriptions: [YES/NO, which]. Pt left the unit at [TIME], [ambulatory / wheelchair], accompanied by [NAME / alone], via [EXIT/ROUTE if known]. ```

Chart note: patient discovered missing from unit

``` [DATE] [TIME LAST OBSERVED] Last direct observation of pt by [NAME, ROLE]: pt [in bed / in chair / in bathroom], [BRIEF DESCRIPTION, e.g., eyes closed, resp even]. [TIME DISCOVERED] Pt not in room on [rounding / med pass / call light response]. Checked bathroom, hallway, [LOUNGE / OTHER AREAS]. Belongings in room: [PRESENT / GONE: list items]. Pt's clothing: [what is missing, if known]. No prior statement of intent to leave documented or reported to this RN. [OR: Pt stated earlier at TIME: PATIENT'S WORDS.]

Lines and devices at time of discovery: [e.g., PIV tubing disconnected at hub, catheter not found in room / catheter found on floor, tip intact / telemetry box missing]. Infusions stopped at [TIME]: [FLUID OR MED, AMOUNT INFUSED]. Last medications given: [DRUG, DOSE, ROUTE] at [TIME]. Relevant risks: [e.g., fall risk, withdrawal risk, recent opioid, self-harm statements, PIV in place, or NONE KNOWN].

Search and notifications: [TIME] Charge RN [NAME] notified. [TIME] Unit and floor search per policy by [NAMES], result: [NOT FOUND / FOUND at LOCATION]. [TIME] Security notified, given description: [AGE, CLOTHING, DEVICES]. [TIME] Dr. [NAME] notified. Told: [FACTS GIVEN]. Response: [ORDERS OR PLAN]. [TIME] House supervisor [NAME] notified. [TIME] Pt's phone [NUMBER] called: [ANSWERED / NO ANSWER / VOICEMAIL LEFT with CONTENT]. [TIME] Emergency contact [NAME, RELATIONSHIP] called: [RESULT]. [TIME] [Police, per policy / per provider order]: [AGENCY], report # [NUMBER if given].

Incident report completed at [TIME], [REPORT NUMBER if assigned]. ```

Message to provider or charge nurse (SBAR)

``` S: This is [YOUR NAME], RN on [UNIT], about [PATIENT NAME], room [ROOM]. The patient [is asking to leave against medical advice / was found missing from the room at TIME].

B: Admitted [DATE] for [DIAGNOSIS]. Currently receiving [KEY TREATMENTS]. Last [OPIOID / SEDATIVE] [DOSE] at [TIME]. Lines: [DEVICES IN PLACE]. Relevant history this admission: [e.g., self-harm statements, withdrawal, fall risk, or none].

A: Last vitals at [TIME]: [VALUES]. Mental status: [WHAT PATIENT SAYS AND DOES]. Plan if leaving: going to [DESTINATION] by [TRANSPORT], dressed in [CLOTHING]. Weather: [IF RELEVANT]. [If missing: last seen at TIME by NAME. Unit search done TIME to TIME, not found. Security notified at TIME.]

R: I am asking you to [come to the bedside to assess capacity and discuss risks / advise on notifying police or family / give orders for line removal or discharge prescriptions]. Please confirm the plan so I can chart it. ```

Words that do the damage

Word or phrase Why it causes trouble Use instead
AMA (for an empty room)Claims a risk conversation that never happenedPt not found in room at [TIME]; no prior statement of intent to leave
eloped (with nothing else)A label with no times, no search, no callsLast observed time, discovery time, search, notifications
MD awareDoesn't say what the MD was toldDr. [NAME] informed of [SPECIFIC FACTS] at [TIME]
risks explainedDoesn't say which risksList the risks in plain words
verbalized understandingYour conclusion, not something you sawPt repeated back in own words that…
A&Ox4 (alone)Doesn't show the patient can follow the decisionWhat the patient said when asked
IV d/c'dDoesn't say whether the catheter came out intactCatheter tip intact, site [DESCRIPTION]
uncooperative, noncompliant, belligerentJudgment words that read badly laterWhat the patient said and did
left without incidentSays nothing about condition, clothing, or planCondition, dress, destination, transport
will continue to monitorCan't be true once the patient is goneLeave it out

If you remember one thing

A stranger should be able to rebuild that patient's last hour on your unit from your clock times and the facts you wrote down.

What goes wrong

The usual mistake is the one-liner: Pt left AMA. MD aware. It feels complete when you write it. It isn't, for three reasons.

1. It hides what the provider was told. MD aware says a call happened. That's all it says. It doesn't show whether you mentioned the slippers, the plan to walk, the hydromorphone 40 minutes ago, or the worrying comment on day shift. The provider can only decide on what you gave them. Later, the chart is the only record of what that was.

2. It blurs two different events. If the patient never said they were leaving, there was no AMA. Write AMA for an elopement and you're claiming a risk conversation that never happened. Write eloped for a patient who told you, talked it through and then walked out, and you've erased the conversation you did have.

3. It has no times. You need the time last observed, the time discovered missing, and the time of each call. They're minutes apart, and the minutes matter. A 30-minute gap between leaving and discovery is one story. A 4-hour gap is a different one. The chart should show which.

The second mistake is quieter: keeping important information outside the chart, on a paper report sheet, a sticky note or in your head. If the next nurse can't see it, it does nothing for the decision while the patient is putting on their coat.

What the guidance says

It is not hypothetical

What happened in 5 court cases — tap to read

John S. Zablotny v. State Board of Nursing, Supreme Judicial Court of Maine, 2017. Opinion

During a nor'easter, a patient wanted to leave AMA, and a night supervisor called the on-call physician about it. He passed on that the patient planned to go to a friend's house. He left out that the patient was dressed in pants, a button-down shirt and moccasin-style slippers, and that he planned to walk. The day nurse's report recorded suicidal comments, but it had never been put in the chart. It turned up about 30 minutes after the patient left. The supervisor then called the patient's wife and, at her request, the police. The patient was found dead near the hospital the next day.

The District Court found unprofessional conduct for "failing to provide the patient with accurate and complete information about the risks he faced upon leaving the hospital against medical advice." It found the Board hadn't proved the other two charges: incomplete information to the physician, and not immediately notifying police or the emergency contact. In weighing those charges, the court noted that the hospital's discharge policy only required contacting the attending physician. Maine's highest court affirmed.

Two lessons for charting:

  • What you tell the provider and what you tell the patient about risk are separate things. Both get examined.
  • Information that sits outside the chart helps no one.

Butler v. Cayuga Medical Center, Appellate Division, Third Department (New York), 2018. Opinion

A patient was triaged in the ED, sent back to the waiting room, and left before a physician saw him. Nobody documented the answers to the follow-up questions on his lethality risk screen. The triage nurse explained her reasoning in a deposition instead. She'd judged he wasn't at risk of eloping because he was with his mother and both had agreed to wait. An expert explained that a patient who presents with "the risk of leaving without being seen" may warrant a higher triage level. The court found that the defendants met their prima facie burden.

The lesson: her reasoning was sound. The problem was that it existed only in her memory, years later. One line in the triage note would have put it in the chart.

Bailey v. Mercy Hospital and Medical Center, Illinois Supreme Court, 2021. Opinion

A patient declined admission from the ED. The physician's discharge note recommended admission and gave the reasons: persistent tachycardia and abnormal labs. It recorded her capacity ("[Jill] does demonstrate decisional capacity."), her agreement to come back if symptoms got worse, and that a reliable partner was with her.

The appeal itself was about jury instructions, not the note. Still, the record shows where a note can come up short. At trial the physician said he hadn't told her he was concerned about GI bleeding or sepsis. He also couldn't recall whether he'd told her the condition might be life-threatening.

The lesson: the strongest note names the specific risks you actually discussed.

William Partin v. Baptist Healthcare System, Inc., U.S. Court of Appeals for the Seventh Circuit, 2025. Opinion (earlier posted version)

This is a physician's retaliation suit, not a charting case. But the facts include a sequence you'll recognize:

  • The patient told the nurse she'd pull the IV out herself if nobody removed it, so staff took it out.
  • After a psychiatric consult found her neither psychotic nor suicidal, and "before a doctor could discharge her, J.C. left the hospital."
  • The nurses had described her orientation in concrete terms: "she was able to state her name, the time, and the month and date of her birth."

The lesson: that last detail is worth far more than a bare A&Ox4.

Read the decisions yourself

Every case below is a published decision on CourtListener. Open them. Nothing on this page asks you to take our word for what a court said — and where we only had the search result rather than the full opinion, it says so.

All the decisions behind this guide, in one page — searchable by court, year, or what happened.

What people say on the floor

Nurses talking to each other about this, quoted as they wrote it. This is opinion, not a source. It is here because it shows what the argument actually is — the rules above come from the decisions and the published guidance, not from these threads.

  • OP, regardless of whether your patients elope (leave without signing AMA paperwork) or sign out AMA, there is very little liability in them leaving PROVIDED you notify the provider every step of the way “so and so wants to leave” “so and so stated they are going to leave if you don’t come see them”

    r/nursing on Reddit: Patient leaving AMA? reddit

  • If they leave AMA with the IV it is on them. ... This right here!! ... That is assault. ... That’s… insane. What the fuck? Do you guys think that’s normal or okay? ... You'll hold down a mentally competent adult who's just refusing to let you take it out? You know that's assault right

    r/nursing on Reddit: Is it legal for a patient to demand and IV not be removed at discharg reddit

  • If he has post Medicare follow up tomorrow call their office and kindly ask them to pull it. God if I had a friend's family member have that happen I'd go over and take care of it. ... ALWAYS come forward about any potential nursing mistake. Talk to charge- likely need to call the pt and e

    r/nursing on Reddit: Accidentally discharged patient with IV still in reddit

  • At my hospital they just made a new policy , get this, we can’t force someone to remove their IV! Before, we’d call security if someone was leaving ama with IV and we would restrain if necessary to remove . Now we can’t.

    r/nursing on Reddit: I let a patient discharge with an IV reddit

What everyone else says

Guidance from professional bodies, insurers and other people who write about this. Useful, but it is advice, not law — that part is above.

How would you chart it?

This is the part we cannot research. If you have a way of writing this that has held up — put it here. No account, no name needed. Nothing that could identify a patient: no room numbers, no dates of birth, no MRNs. Use placeholders, the example still works.

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