NOTE OF DISCHARGE OR VOLUNTARY HOSPITAL DISCHARGE.

(Suggested format)

Through this document, the patient, and his or her closest family member, guardian or legal
representative, requests discharge, with full knowledge of the consequences that said act could
cause, since it is carried out against medical recommendation. This document will relieve the
establishment of responsibility and will be issued in duplicate, leaving one copy in its possession
and another will be provided to the user.

Mexico City, DF now_________

1. IDENTIFICATION of the patient and his family member.

Patient's full name: ____________________________________ Age: ___________
Family member's full name: _____________________________________ Age: __________
Relationship: ___________________________

2. Write clearly the reasons for the

discharge:________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_______________

3 Clinical summary (will include at least):

- Shipping reason
- Diagnostic impression (including abuse and dependence on tobacco, alcohol and other
psychoactive substances)
- Therapeutics used, if any.

4 Recommended measures to protect the patient's health and to address risk factors (include
health measures to reduce the risk of contagion for family members and the general
population that the patient and their family must follow)

5. Full name and signature of the doctor who grants the response

6. Full name and signature of the doctor issuing the form

7. Full name and signature of two witnesses (one designated by the hospital and another
designated by the patient or their family member)
 8. Perform in duplicate, one original
remains in the file and another is
provided to the user.

9. Notify Social Work, Epidemiology and the Legal Division of the voluntary discharge.

Legal sustenance.
REGULATIONS of the General Health Law on the Provision of Medical Care Services. ARTICLE 79.- In case
of voluntary discharge, even against medical recommendation, the user, where applicable, a family member,
guardian or legal representative, must sign a document that clearly expresses the reasons for the discharge. ,
which must also be signed by at least two suitable witnesses, of which one will be designated by the hospital
and another by the user or the person who issues the document on behalf. In any case, the document referred
to in the previous paragraph will relieve the establishment of responsibility and will be issued in duplicate,
leaving one copy in its possession and another will be provided to the user.
Federal Penal Code . Book Second Title Seven - Crimes against Health Chapter II - The Danger of
Contagion. Article 199-Bis
Anyone who, knowing that he or she is sick with a venereal disease or other serious illness in an infectious
period, puts the health of another in danger of contagion, through sexual relations or other communicable
means, will be punished from three days to three years in prison and up to forty days fine. If the disease
suffered is incurable, the penalty of six months to five years in prison will be imposed. (this is followed by a
complaint, that is, a person who believes that he or she was infected by the patient files a complaint against
him or her so that the corresponding investigations can be initiated)

Bibliography:
Mexican Official STANDARD NOM-004-SSA3-2012, From the clinical file.
REGULATIONS of the General Health Law on the Provision of Medical Care Services. ARTICLE 79.
Federal penal code. Book Second Title Seven - Crimes against Health Chapter II - The Danger of Contagion. Article 199-Bis