Charting a Patient Leaving Against Medical Advice

Every question in this set, with the answer

Use this to review after you finish — or instead of the timed version, if you would rather just read.

1. At 0900, you offer the scheduled enoxaparin 40 mg subcutaneous dose. The patient declines, saying previous injections caused painful bruising. You review the medication’s purpose and the risk of a clot without recommended prophylaxis; the patient explains the purpose back and still declines. At 0910, Dr. Chen is notified and says she will review prophylaxis options at the bedside. Which note best follows the guidance?

   1. 0900: Scheduled enoxaparin 40 mg subcutaneous offered. Patient declined due to painful bruising after previous injections. Reviewed purpose for blood-clot prevention and risk of clot without recommended prophylaxis. Patient explained the medication’s purpose and continued to decline. Dose not administered. 0910: Dr. Chen notified of refusal and concern; plans bedside review of prophylaxis options. Follow-up pending.
   2. 0900: Patient refused Lovenox. Educated on risks. MD aware.
   3. 0900: Patient noncompliant with anticoagulant because she does not like injections. Verbalized understanding. Dr. Chen will handle.
   4. 0900: Enoxaparin held per patient request due to bruising. Will try again later if patient changes mind.

   Answer: 0900: Scheduled enoxaparin 40 mg subcutaneous offered. Patient declined due to painful bruising after previous injections. Reviewed purpose for blood-clot prevention and risk of clot without recommended prophylaxis. Patient explained the medication’s purpose and continued to decline. Dose not administered. 0910: Dr. Chen notified of refusal and concern; plans bedside review of prophylaxis options. Follow-up pending.

   The correct note names the offered medication, the patient’s stated reason, the discussion, the patient’s response, the notification, and the pending next step. The other notes are vague, label the patient, guess at motives, or omit what was discussed and what happened next.

2. At 1635, a patient leaves before recommended evaluation is complete. You provided written instructions, the patient signed the AMA form, and you observed the patient leave ambulatory with a sister. Which details belong in the departure note? Select all that apply.

   1. The departure time and what you observed about how the patient left
   2. The instructions you actually provided before departure
   3. Whether the patient signed the AMA form
   4. A statement that all possible discharge teaching was completed, even if some topics were not reviewed
   5. Your assumption about the patient’s destination if the patient did not tell you

   Answer: The departure time and what you observed about how the patient left, The instructions you actually provided before departure, Whether the patient signed the AMA form

   The correct choices document the observed departure, the instructions actually provided, and whether the form was signed. The incorrect choices overstate what happened or add assumptions instead of keeping the note factual.

3. At 1400, a patient scheduled for repositioning says left hip pain is 7/10 and asks for pain medication before a full left-side turn. The patient accepts a small assisted weight shift and heel off-loading now. After PRN medication, the patient accepts assisted repositioning at 1435. Which wording best fits the guidance?

   1. 1400: Patient declined full left-side turn at this time due to left hip pain 7/10; accepted small assisted weight shift and heel off-loading. PRN analgesic administered; at 1435 pain improved and patient accepted assisted repositioning.
   2. 1400: Patient refused turning and was noncompliant until pain medication was administered.
   3. 1400: Patient refused all repositioning. Educated on pressure-injury risk. Verbalized understanding.
   4. 1400: Turning omitted due to pain; no refusal because patient later complied.

   Answer: 1400: Patient declined full left-side turn at this time due to left hip pain 7/10; accepted small assisted weight shift and heel off-loading. PRN analgesic administered; at 1435 pain improved and patient accepted assisted repositioning.

   The correct note distinguishes a delay in full turning from refusal of all repositioning and records the care accepted. The other choices label the patient, overstate the refusal, or leave out the sequence of accepted care and reassessment.

4. At 1015, a patient declines a scheduled assessment. You notify the provider and receive instructions for a later reassessment. Which charting elements close the communication loop? Select all that apply.

   1. The provider’s name and the time notified
   2. The key information you reported about the declined assessment
   3. The provider’s response
   4. Any follow-up that remains pending
   5. The phrase “MD aware” without additional detail

   Answer: The provider’s name and the time notified, The key information you reported about the declined assessment, The provider’s response, Any follow-up that remains pending

   The correct choices identify who was notified, when, what was reported, the response, and pending follow-up. “MD aware” is too vague because it does not tell the next nurse what information was shared or what still needs to happen.

5. A patient requests to leave before an evaluation is complete. The clinician discusses risks with the patient while you are not present. Later, you see the clinician’s note and document your own interactions and the departure. What should your nursing note do about the clinician’s discussion?

   1. State only what you observed, document your own interactions and departure details, and reference the clinician’s note for the clinician’s discussion.
   2. Chart that the clinician explained risks in your presence because you confirmed later that the discussion occurred.
   3. Write “risks explained; patient understood” so the chart has a short summary of the discussion.
   4. Leave out the clinician’s discussion entirely because you did not witness it.

   Answer: State only what you observed, document your own interactions and departure details, and reference the clinician’s note for the clinician’s discussion.

   The correct option avoids charting an unwitnessed explanation as if you observed it and still points the reader to the clinician’s documentation. The other choices either claim more than you observed, use vague shorthand, or omit relevant context.