Patient signed out to Dr. ***. Pending items: ***. Discussed plan of care with Dr. ***, but the final disposition and original plan may change depending on the patient's medical needs.
Patient was seen in this ED for *** on ***. Tests performed revealed ***. Treated with *** with/without relief. Discharged/admitted/transferred with diagnosis of *** and with Rx for ***.
Updated patient with test results and diagnosis. Discussed discharge instructions, return indications, and importance of follow up. Patient expresses understanding. Stable for discharge.
Addressed diagnostic uncertainty and thus importance of follow-up. Aftercare instructions and return indications discussed. Patient acknowledges understanding. Stable for discharge
Assumed care of patient from ***. *** pending.
Patient will be admitted to ICU/Med Surg/Tele. Patient updated regarding results and plan for admission. Patient understands and is on board with plan.
The patient refused further evaluation and treatment and elected to leave against medical advice. The patient had no altered level of consciousness and no signs of intoxication. The patient's judgment capabilities were intact. The patient understands their current condition and treatment and was able to communicate their choices clearly. The patient was counseled that by leaving AMA and refusing further evaluation and treatment, there is risk that includes but is not exclusive of worsening illness, permanent disability and/or death. Patient indicates understanding and was encouraged to return to the Emergency Department as soon as possible for further evaluation and management, and for any signs of deteriorating or worsening condition.
Patient still offered every available resource for treatment of the medical condition, I answered all the patient's questions and offered care at any time if the patient chooses to return. I have also recommended that the pt follow up with their primary care provider within 24 hours for further evaluation and care.