Decision-Making Capacity Evaluation Report (Older Adult)

Patient Name: [Patient full name]

DOB: [Date of birth]

MRN: [Medical record number]

Preferred Language: [Language]

Evaluation Date/Time: [Date and time of evaluation]

Location: [Care setting and unit/clinic]

Modality: [in-person / telehealth]

Evaluator: [Name, credentials]

Referring Party: [Name, role, service]

Purpose/Decision(s) to be Evaluated: [Concise description of decision(s)]

(For any unavailable header field, enter "Not available" rather than leaving blank.)

Executive Summary

• Decision(s) evaluated: [List each specific decision]
• Capacity determination(s): [Has Capacity / Lacks Capacity / Marginal / Indeterminate] (Match each decision above.)
• Key observations: [1–2 objective phrases describing performance in attention, memory, language, or other relevant domains]
• Interpretive conclusions: [1–2 phrases linking observed abilities to decision demands]
• Decision supports attempted and effect: [Brief list of accommodations/supports tried and observed impact] (If not attempted, state why.)
• Recommended next step: [Time-sensitive action such as proceed with patient's choice / initiate surrogate pathway / reassess after optimization / consult ethics]

Referral Question and Decision(s) at Issue

[Who requested the evaluation and stated reason for consult] (If referral question was unclear, specify what was evaluated and why.)

1. [Decision 1 framed concretely, e.g., capacity to accept/refuse specific treatment or select disposition option]
2. [Decision 2 framed concretely] (Include only if more than one decision is being evaluated.)

Urgency: [Low / Moderate / High] | Consequence severity: [Low / Moderate / High]

Consent and Role Clarification

[Patient consented / Patient declined] to participate in the capacity evaluation. (If declined, include stated reason if given and document what could be concluded from records and collateral alone.)

Limits of confidentiality were explained. The evaluator clarified that this is a clinical opinion regarding medical decision-making capacity for specific decisions at a specific time and is not a legal determination of competency.

Sources of Information

Patient Interview: [Yes / No], approximate duration: [minutes] (If no, explain why.)

Collateral Contacts:

• [Name, relationship, date of contact] (Add multiple as needed; if none obtained, state "No collateral available or obtained.")

Records Reviewed: [List key documents: prior cognitive testing, advance directives, prior capacity notes, nursing notes, progress notes, medication list, labs, imaging, OT/PT assessments, social work notes with dates if available]

Communication Aids Used: [Interpreter / Hearing aids / Glasses / Written materials / Visual aids / Amplification / None] (Specify language if interpreter used.)

Clinical Context

[Brief summary of pertinent medical, neurologic, and psychiatric conditions affecting cognition: dementia, delirium, stroke, TBI, serious mental illness, substance use, sleep, pain, sensory deficits, current medications with cognitive effects; include acute issues prompting consult]

[Functional baseline: living situation, ADL/IADL independence, supports in place; documented prior values/preferences relevant to the decision such as advance directive, POLST, consistent prior statements] (If baseline unknown, state "Baseline cognitive/functional status unknown; collateral not available.")

Decision Supports and Communication Optimization

• Environment: [Quiet room / Minimized distractions / Optimal timing for alertness / Not optimized due to urgency] — Outcome: [Improved / No change / Unable to assess]
• Sensory accommodations: [Glasses / Hearing aids / Amplifier / Written materials / Large print / Interpreter / None needed] — Outcome: [Improved / No change / Not applicable]
• Communication strategies: [Slowed speech / Plain language / Teach-back / Visual aids / Repetition / Chunking information] — Outcome: [Improved / No change]
• Medical optimization: [Addressed pain / Sleep / Hydration / Delirium contributors / Medication timing / None] — Outcome: [Improved / No change / Not applicable]
• Supported decision-making: [Trusted person present / Values clarification / Breaking decision into parts / None] — Outcome: [Improved / No change]

(If nothing tried due to urgency, briefly explain why.)

Mental Status and Behavioral Observations

• Appearance/behavior: [Grooming, cooperation, psychomotor activity]
• Level of arousal: [Alert / Drowsy / Fluctuating]
• Speech/language: [Rate, volume, articulation; aphasia or comprehension deficits if present]
• Mood/affect: [Patient-reported mood; observed affect]
• Thought process/content: [Coherence, organization; delusions or paranoia if present]
• Perceptions: [Hallucinations present / None observed]
• Attention: [Sustained and divided attention findings]
• Orientation: [Person / Place / Time / Situation]
• Memory: [Immediate and short-term recall; confabulation or perseveration if present]
• Insight/judgment: [Observed findings]
• Reliability concerns: [Confabulation / Suggestibility / Inconsistency / None]

(For any domain that could not be assessed, state "Unable to assess [domain] due to [reason].")

Cognitive Assessment

[Tool(s) administered, score(s), and brief interpretation tied to decision demands] (If none administered: "No formal cognitive screening administered; assessment based on clinical interview and decision-specific questioning." Include relevant functional observations from OT/PT/nursing if available.)

Decision-Specific Capacity Analysis

(Repeat the following subsections for each decision listed above.)

[Decision #1 Title]

Decision and Options: [Restate specific decision and available options including no treatment if applicable]

Disclosure Provided: [Diagnosis/problem, proposed intervention, benefits, risks, and reasonable alternatives; how information was communicated and optimized]

Patient Responses by Decisional Ability:

• Expressing a Choice: Prompt: [prompt used]; Response: "[Patient's pivotal statement]"; Interpretation: [Clear and stable / Vacillating / Unable to state preference]
• Understanding: Prompt: [prompt used]; Response: "[Patient's paraphrase]"; Interpretation: [Accurate / Limited / Misconstrued]
• Appreciation: Prompt: [prompt used]; Response: "[Patient's statement applying information to self]"; Interpretation: [Recognizes personal consequences / Denies personal relevance] (Note: Disagreement with recommendations alone does not indicate impaired appreciation; explain basis if concluding impairment.)
• Reasoning: Prompt: [prompt used]; Response: "[Patient's comparison, tradeoffs, or rationale]"; Interpretation: [Logical and value-consistent / Illogical / Concrete / Perseverative]

Values and Preferences: [Expressed priorities such as independence, avoiding suffering, longevity, religious beliefs, financial concerns; whether decision aligns with longstanding values or appears driven by acute mental state]

Voluntariness Screen: [No concerns for undue influence observed] (If concerns present: document who was present, whether others answered for patient, signs of coercion or exploitation.)

Capacity Conclusion for This Decision: [Has Capacity / Lacks Capacity / Marginal / Indeterminate] — [Brief justification linking observed abilities to decision complexity and risk]

[Decision #2 Title]

(Include only if a second decision is being evaluated. Use same structure as above.)

Risk Analysis

• Risk if proceeding with patient's preferred option: [Immediacy, severity, specific potential harms]
• Risk of alternative(s) including no treatment: [Immediacy, severity, specific potential harms]
• Scope of capacity: [Whether patient retains capacity for lower-stakes sub-decisions even if lacking capacity for the primary decision]

Capacity Determination Summary

• [Decision 1]: [Has Capacity / Lacks Capacity / Marginal Capacity / Indeterminate]. At the time of evaluation on [date/time], the patient demonstrated [capacity status] for [specific decision]. (If indeterminate, state what is needed to resolve.)
• [Decision 2]: [Has Capacity / Lacks Capacity / Marginal Capacity / Indeterminate]. At the time of evaluation on [date/time], the patient demonstrated [capacity status] for [specific decision]. (Include only if applicable.)

(Capacity conclusions apply to specific decisions at specific times. Avoid global statements such as "patient is incompetent.")

Recommendations

• Immediate clinical actions: [Treat reversible contributors; optimize timing/setting; manage pain, sleep, delirium; reassess]
• Decision supports to preserve autonomy: [Accommodations, teach-back, values clarification, supported decision-making partner]
• Surrogate pathway if lacking capacity: [Identify appointed healthcare agent/advance directive; default surrogate per local policy; document discussions]
• Safety planning and supervision needs: [Monitoring level, environment, elopement risk, exploitation protection]
• Referrals/consults: [Geriatrics / Psychiatry / Neurology / Ethics / Social Work / APS / Palliative Care] (Include only those indicated.)
• Reassessment plan: [When to reassess; conditions under which capacity may improve; triggers for re-evaluation]

Limitations

[Note any factors limiting evaluation completeness or certainty: missing collateral, patient somnolence, language barriers, incomplete records, single time-point in fluctuating condition, telehealth constraints] (Use explicit statements such as "Unable to assess due to..." rather than omitting.)

Signature

[Evaluator name], [Credentials]

Date/Time Signed: [Date and time]