Medical Decision-Making Capacity Evaluation Note

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

Evaluator: [Name, role, service]

Location/Setting: [Location and context]

Patient Identifiers: [Per institutional policy]

Persons Present: [Names, roles, relationships]

Communication Method: [Language used; interpreter type and ID if applicable; assistive devices]

Information Sources: [Patient interview; chart review; collateral contacts; outside records]

Reason for Evaluation

[Reason for capacity assessment and requesting party] (Briefly explain what prompted concern about capacity—such as treatment refusal, mental status change, intoxication, high-stakes consent, or inconsistent choices—and identify who requested the assessment.)

Decision Evaluated: [Specific decision being assessed with clinical indication, urgency, and options discussed] (Use format: "Capacity for: consent vs. refusal of [specific intervention] for [indication].")

Information Disclosed and Supports Provided

• [Diagnosis or working diagnosis disclosed]
• [Nature and purpose of recommended intervention]
• [Material risks and benefits of the recommended intervention]
• [Alternatives discussed, including no treatment, with material risks and benefits]
• [Consequences of refusal]
• [Communication supports used: plain-language explanation; teach-back; visual aids; written materials; involvement of support persons]
• [Environmental or physiologic optimization: quiet setting; pain control; timing to reduce fatigue] (Include if applicable)
• [Limitations on disclosure due to emergent instability, if any]

Communication and Voluntariness Assessment

• [Language proficiency and interpreter use; rationale if family interpreted]
• [Hearing, vision, or speech impairments and accommodations provided]
• [Cognitive load factors and mitigation steps: pain, fatigue, sedation, intoxication]
• [Relevant cultural or religious considerations affecting communication or decision-making] (Include if applicable)
• [Voluntariness assessment: evidence of coercion or undue influence; private conversation conducted; patient's stated sense of freedom to choose]
• Assessment Validity: [valid / limited / deferred] (If limited or deferred, specify unmitigated barriers and next steps.)

Relevant Clinical Context

• [History relevant to decisional abilities: neurocognitive disorder, prior strokes or TBI, developmental disability] (Include if applicable)
• [Current delirium risk factors, precipitants, and status]
• [Active psychiatric symptoms relevant to decision and their impact] (Include if applicable)
• [Substance intoxication or withdrawal status] (Include if applicable)
• [Medications affecting cognition: sedatives, anticholinergics, opioids, with recent doses and timing] (Include if applicable)
• [Baseline function and prior decision-making style from collateral, with source identified] (Include if collateral available)
• [Mental status findings: level of consciousness; attention; orientation; thought process; perceptual disturbances; delusions relevant to decision; insight]
• [Cognitive screening tool and score] (If performed; note that results inform but do not determine capacity.)
• [Physiologic contributors and steps taken to address] (Include if applicable)

Capacity Assessment

Decision Assessed: [Specific decision] Stakes: [low / moderate / high] (Based on risk of harm, reversibility, and urgency.)

Understanding

[Patient's explanation of their condition, the recommended intervention and alternatives, key risks and benefits, and what happens with no treatment] (Use brief direct quotes or faithful paraphrases. Note response to re-explanation and whether misunderstandings improved. Assess whether patient grasps the meaning, not medical precision.)

Ability: [intact / partial / absent / not assessable] (If not assessable, specify why.)

Appreciation

[Patient's recognition that the information applies to them personally: acknowledges diagnosis; believes they face stated risks; understands personal impact of acceptance or refusal] (If disagreement with diagnosis, indicate whether due to fixed false beliefs versus values-based disagreement. Specify how any psychosis or delusions distort appreciation of this decision.)

Ability: [intact / partial / absent / not assessable] (If not assessable, specify why.)

Reasoning

[Patient's comparative weighing of options; stated values and goals; pros and cons considered; internal consistency; responsiveness to new information] (Document the reasoning process, not just the choice. Note if reasoning is reality-based versus driven by disorganization or delusions. Sound reasoning can support an unwise choice—disagreement with medical recommendation does not equal incapacity.)

Ability: [intact / partial / absent / not assessable] (If not assessable, specify why.)

Ability to Express a Choice

[Patient's stated decision as direct quote; clarity and stability of choice during interview] (If unable to express a choice, specify whether due to communication barriers, ambivalence, or fluctuating consciousness.)

Ability: [intact / partial / absent / not assessable] (If not assessable, specify why.)

[Factors limiting reliability of this assessment and reassessment plan if applicable] (Include if fatigue, pain, agitation, interpreter limitations, or other factors affect reliability.)

Determination

Determination: [Has capacity / Lacks capacity / Indeterminate capacity] for [specific decision].

[Rationale summarizing what the patient demonstrated in each ability, impairments observed and their reversibility, and why evidence meets threshold for this determination] (State that this determination applies to the specified decision at the time of evaluation. Note potential for fluctuation if relevant.)

Surrogate Decision-Making

(Include this section only when patient lacks or has indeterminate capacity. Omit entirely if patient has capacity.)

• [Advance care planning documents reviewed: advance directive, POLST, healthcare proxy; summary of relevant contents]
• [Surrogate decision-maker: name, relationship, how identified per policy or document]
• [Discussion with surrogate: options presented; patient's known prior preferences for substituted judgment; best-interest rationale if preferences unknown]
• [Patient involvement despite incapacity: expressed preferences, assent, known values] (Include if applicable)
• [Consultations requested and specific question posed] (Include if ethics, psychiatry, or other consultation obtained)

Plan and Communication

• [Parties informed of determination: patient, surrogate, nursing, attending, consultants; content of explanation]
• [Immediate clinical plan linked to capacity finding: proceed with consented treatment; respect informed refusal; treat reversible causes and reassess; implement surrogate-authorized plan]
• [Reassessment plan with triggers and timeframe] (Include if capacity may change; e.g., after delirium treatment, after sedation clears.)
• [Formal capacity instrument used] (If applicable; note that results informed but did not solely determine clinical judgment.)