Emergency Room Release Form Template for England and Wales

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Key Requirements PROMPT example:

Emergency Room Release Form

"I need an Emergency Room Release Form for our small private hospital in Cardiff that includes enhanced mental capacity assessment clauses and bilingual English-Welsh text, to be implemented by March 2025."

Document background

The Emergency Room Release Form is essential documentation when patients choose to leave medical care contrary to professional recommendations. Under English and Welsh law, patients have the right to refuse treatment, but healthcare providers need protection from potential liability. This document records the patient's informed decision, confirms their capacity to make such decisions, and documents that risks were properly explained. It's particularly crucial in emergency settings where the consequences of leaving could be severe. The form should detail the specific treatments being declined and include clear warnings about potential health risks.

Suggested Sections

1. Patient Information: Personal details including full name, date of birth, address, contact information, and medical record number

2. Treatment Summary: Brief description of emergency care provided, symptoms presented, and initial diagnosis

3. Discharge Against Medical Advice Statement: Clear statement acknowledging that the patient is leaving against medical advice and understanding of risks

4. Capacity Declaration: Confirmation that the patient has the mental capacity to make informed decisions about their medical care

5. Release of Liability: Legal waiver releasing the hospital and medical staff from liability for consequences of leaving

Optional Sections

1. Witness Statement: Additional verification by witness when patient's capacity might be questioned or in high-risk cases

2. Interpreter Declaration: Statement confirming accurate translation of all information when patient requires language assistance

3. Next of Kin Notification: Documentation of family notification when appropriate or required

Suggested Schedules

1. Schedule A - Follow-up Care Instructions: Detailed post-discharge care guidelines and recommendations

2. Schedule B - Medication List: Current medications, new prescriptions, and medication instructions

3. Schedule C - Risk Assessment Form: Documentation of specific risks identified and potential consequences of leaving

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

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Authors

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