judgement/insight and AMA patients

[sassyann85]

How do you typically document judgement and insight on patients signing out AMA? Specifically, patients with drug/ETOH problems that arent suicidal and so can't be held, but sign out AMA and plan to use again.

[Jules A, MSN]

As a NP I usually do judgement poor and insight either fair or poor depending on whether they were verbalizing fair or poor insight.

[sassyann85]

when other pts get d/c to outpatient treatment or whatever, sometimes they really minimize the severity of their condition but they are able to care for themselves and I think recognize if the were decompensating, and I wonder about what to chart bc I was thinking if I do fair or poor insight, it means they shouldnt be getting discharged or that they wont be safe...

[Jules A, MSN]

I almost always chart fair/fair when a patient is being discharged from my acute unit. Every so often I'll do insight good but again judgement is almost always fair. Acute units are for stabilization and unfortunately in my experience very few are much better than fair at discharge. Its similar to documenting suicidality, I always clarify "at present patient denying SI, no threats or acts of self harm at this time" because as we all know that can change from minute to minute.