A capacity assessment, or capacity evaluation note, records whether a patient can make one specific decision at one time: what they were told, the four abilities with their own words as evidence, your conclusion, and who decides if they can’t. Copy the free template, see a capable refusal of hip surgery and a delirious patient refusing antibiotics for sepsis, and check what each part needs.
Blank capacity assessment template
FreeCAPACITY ASSESSMENT Decision-making capacity for one decision, at one time Patient: [Name] Date of birth: [Date] Date and time: [Date, and start and end time] Setting: [Ward, emergency department, clinic, home, or care home] Assessor: [Name, credentials, role] Requested by: [Clinician or team, and the question they asked] Present: [Family, staff, interpreter, or none, and whether the patient was seen alone] THE DECISION Decision: [One specific decision, e.g. consent to or refusal of a named treatment, a procedure, or a discharge destination] Why capacity is in question: [Refusal of recommended care, new confusion, known cognitive impairment, mental illness, or a concern from family or staff] Urgency: [Whether the decision can wait until the patient may be better able to decide, and why] INFORMATION GIVEN The condition and the proposal: [What was explained, in plain words] Benefits: [Expected benefits of the proposed treatment] Risks: [Common and serious risks] Alternatives, including no treatment: [Each option, and what is likely to happen with each] How it was given: [Who explained it, in what language, with an interpreter, hearing aids, glasses, or written material, and how many times] FACTORS THAT COULD BE FIXED Delirium screen: [Attention testing and the result, e.g. CAM or 4AT] Medical causes: [Pain, low oxygen, infection, fever, glucose, sodium, sedating medicines, intoxication or withdrawal] Communication: [Hearing, vision, speech, language, and the interpreter used] Timing and setting: [Time of day, fatigue, privacy, people the patient trusts] Steps taken: [What was done to help the patient decide, and what could not be fixed] THE FOUR ABILITIES Communicates a choice: [The choice, in the patient's words, and whether it stayed the same] Understands the information: [The patient's own account of the condition, the options, and their risks and benefits] Appreciates how it applies to them: [Whether they accept the facts apply to them, in their words; any belief that distorts them] Reasons about the options: [How they compare the options and their consequences, in their words] Fits the patient's values: [Whether the choice matches values they have held before, and the source] Collateral history: [From whom, with the patient's agreement, and what they said, or none] Other testing: [A cognitive test and score as background, a structured tool such as the MacCAT-T, or none] CONCLUSION For this decision, at this time: [Has capacity, or lacks capacity] Reasons: [Which abilities were intact or impaired, and the evidence above] Cause and outlook: [The cause of any impairment, and whether it is likely to improve] Patient told: [How the finding was explained, the patient's response, and any right to have it reviewed where you practice] IF THE PATIENT LACKS CAPACITY Substitute decision-maker: [Name, relationship, phone, and authority: named in a document, appointed by a court, or the default order where you practice] Known wishes and values: [Advance directive, earlier capable wishes, and values, or none known] Decision made: [What the substitute decided, and when] If no one can be reached: [Emergency treatment under the rules where you practice, what was given, and why it could not wait] PLAN Reassess: [Date, or the change that will prompt it, e.g. delirium clearing or a new decision] Next steps: [Treatment, second opinion, psychiatry, ethics or legal consultation] Told: [Treating team, and family with the patient's agreement] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Orthopedic ward, geriatric medicine consult, in person on two mornings
76-year-old woman with mild Alzheimer’s dementia, admitted last evening after a fall at home, with an intertrochanteric fracture of the left hip. The orthopedic surgeon recommends fixation with a hip nail within 48 hours of admission. She declines. Orthopedics asked whether she has the capacity to refuse. Decision: consent to or refusal of hip nail fixation. Urgency: it can wait a day at most, as complications rise when surgery is delayed. Seen at 10:30 and again at 08:00 the next morning in a side room. Her daughter joined for the second half of the first visit, at her request.
Given by the surgeon at 07:30, then again by me in short steps, with her hearing aids in and glasses on. The break: the thigh bone is broken just below the hip joint. The operation: a metal rod inside the bone with a screw into the ball of the hip, through small cuts, under a spinal or general anesthetic. Benefits: less pain within days, standing with a walker the next day, and the best chance of walking again. Risks: bleeding and transfusion, infection, blood clots, confusion after surgery that can last days to weeks, the fixation failing, and a small chance of dying around the operation. No operation: pain relief and a nerve block; the bone may knit over 2 to 3 months, often shorter and turned out; moving will hurt for weeks; she would most likely not walk again; and pneumonia, pressure sores, blood clots, and death in the coming months are all more likely than with surgery.
Fascia iliaca block in the emergency department last night; pain 2 out of 10 at rest, 6 on moving. Last opioid dose, oxycodone 2.5 mg, 5 hours before the first visit. Alert. Named the months of the year backwards without error. Confusion Assessment Method negative, and her daughter sees no change from her usual thinking. Afebrile, SpO2 96% on room air, sodium 139 mmol/L, glucose normal. English is her first language. Mid-morning, her best time of day, her daughter says.
“I don’t want the operation.” The same answer to the surgeon, the night nurse, her daughter, and me, at both visits.
Asked to explain it back: “The bone’s broken near the hip. They’d put a rod in it. Without it, it might knit, crooked, but I’d be in a chair, and it would hurt for a while.” Named infection, clots, and “being muddled after” as risks. The next morning she recalled the same points without prompting, though not the word “nail.”
“It’s my hip, and I know it won’t come right on its own. I might never walk again, and I could die sooner without the operation. I understand that.” She knows she has a memory problem, and that an anesthetic could make it worse for a while. She doesn’t deny the break or expect to walk on it.
Compared the two: “With the rod I might walk, but I might end up like Frank, weeks in hospital, not knowing anyone, then a home. Without it I’d be in a chair, but at home, or at my daughter’s. I’d rather have that.” Asked what would change her mind: “If I were 60, I’d have it done.” Weighed the higher risk of dying and accepted it: “I’ve had a good long life.”
Her daughter, named as her decision-maker in a 2023 advance directive, says her mother has said for years that she would never have major surgery. Her husband, Frank, had a hip operation in 2019, followed by weeks of delirium and a move to a care home, where he died. Her advance directive declines treatment “likely to leave me in a nursing home.” Background: MoCA 21 out of 30 at the memory clinic in May 2026. Lives alone, with a home care worker 3 mornings a week; takes her own pills from a blister pack.
Has capacity to refuse hip nail fixation, at this time. She communicates a stable choice, understands the information, appreciates that it applies to her and what refusing means, and reasons about the options in line with values she has held for years. Her dementia and the seriousness of the choice called for a careful look; neither shows incapacity on its own. Told her the finding; she said, “Good. Then that’s settled.”
Refusal recorded; surgeon told, and surgery cancelled. Non-operative plan agreed with orthopedics: regular pain relief, a repeat nerve block if needed, bed to chair with physiotherapy as pain allows, blood clot prevention, pressure care, and bowel care. Social work to arrange more home care or a move to her daughter’s. Told her she can change her mind at any time; the surgeon will see her again in 2 days. Her daughter was upset at first, then said she would support her mother’s choice. Reassess if she becomes confused or asks for surgery. If she later loses capacity, this capable refusal should guide her daughter’s decisions.
Emergency department, emergency physician at the bedside
54-year-old man with type 2 diabetes, brought in by his wife after 3 days of cough and fever and a day of confusion. T 39.2 °C (102.6 °F), HR 122, BP 88/54, RR 28, SpO2 88% on room air. Lactate 4.1 mmol/L. Right lower lobe consolidation on chest X-ray. Treated as sepsis from pneumonia. He pulled out his first IV and refuses antibiotics, fluids, and further blood tests. Decision: consent to or refusal of IV antibiotics and fluids. Urgency: it can’t wait; delaying antibiotics in sepsis with low blood pressure raises the risk of death. Assessed at 14:20, 10 minutes after the refusal, with his wife at the bedside.
Explained in short sentences, twice, with his wife beside him: he has a serious chest infection that is affecting his whole body and dropping his blood pressure. Treatment: antibiotics and fluids through a drip, and oxygen. Risks: an allergic reaction, and a sore arm. Tablets at home wouldn’t be enough at this stage. Without treatment, he could get much sicker quickly, need intensive care, or die.
Delirium: his wife says he was well until yesterday, and his confusion comes and goes. Could not say the days of the week backwards past Friday; drifted off mid-sentence; thought he was at the garage, and gave the year as 2019. Confusion Assessment Method positive. Causes being treated: sepsis, fever, and low oxygen; SpO2 93% on 3 L by nasal cannula. Fingerstick glucose not low. No alcohol or sedatives at home, his wife says; none given here. Hearing normal; English is his first language. Moved to a quieter bay, one person speaking, his wife holding his hand.
“No. Get away from me.” Said no to the drip and the antibiotics, then held out his arm for the blood pressure cuff, then said no again. Not a stable choice.
Could not say back any part of the information, even in short steps. Asked why he was in hospital: “I came to pick up the truck.”
Denies being unwell: “I’m fine, I just need to sleep.” Believes the nurses are “putting something in the bags to knock me out.” This belief, and the delirium, stop him from applying the information to himself.
Could not compare treatment with no treatment, or say what might happen without it. Each answer came back to going home to sleep.
His wife: until yesterday he was working as an electrician and made all his own decisions. He sees his doctor when he is unwell and takes his medicines. No advance directive. “He’d want everything done. He’d be horrified to know he said no.”
Lacks capacity to consent to or refuse IV antibiotics and fluids, at this time. He states a choice, but it isn’t stable, and he can’t understand the information, appreciate that it applies to him, or reason about the options. Cause: delirium from sepsis and low oxygen, likely to improve with treatment. Told him simply that the infection is making it hard to think clearly, and that his wife will help decide for now.
His wife, by the default order where we practice; no one named in a document. She heard the information at the bedside and, from what he has said and done when well, consents to IV antibiotics, fluids, oxygen, and blood tests. With her talking to him, he let the nurse place a new IV. Ceftriaxone and azithromycin started at 14:45, with IV fluids. No restraint or sedation needed. This finding covers today’s treatment for sepsis; any new decision, such as intensive care, goes to his wife while he lacks capacity, and back to him once he regains it.
Reassess daily, and as soon as the delirium clears. Delirium care: treat the infection, oxygen, fluids, his wife or another familiar person at the bedside, a clock and calendar in view, lights off at night, and no benzodiazepines. Addendum, day 3, medical ward: afebrile, BP 124/76, Confusion Assessment Method negative, attention intact. He explained the infection and its treatment in his own words and chose to continue antibiotics: “I don’t remember saying no. Of course I want them.” Has capacity for this decision now; his wife told.
Capacity is judged for one decision at one time. Name the decision precisely, and say why capacity is being questioned now.
Avoid: Assessing “capacity” in general. A patient can be able to refuse a blood test and unable to decide about surgery on the same day.
What the patient was told, so a reader can judge what they were expected to understand.
Avoid: Finding a patient unable to understand information they were never given clearly. Explain first, then assess.
What might be making the patient less able to decide right now, and what you did about it before you judged.
Avoid: Assessing at 3 a.m., in pain, without hearing aids, and recording the result as final. If the decision can wait, fix what you can and go back.
The heart of the note: the four abilities described by Appelbaum and Grisso, each with the patient’s own words as evidence. Laws word their tests differently, so check the test where you practice.
Avoid: Yes-or-no questions. “Do you understand the risks?” invites a yes. Ask the patient to tell you the risks, and write down what they say.
Your finding for this decision, at this time, the reasons for it, and how you told the patient.
Avoid: A conclusion that rests on a diagnosis. Dementia, psychosis, or an intellectual disability doesn’t by itself mean a patient lacks capacity.
If the patient lacks capacity, who decides now and on what basis, and when you will look again.
Avoid: A finding that is never revisited. Capacity can return as delirium clears, and the patient should get the decision back.
“Lacks capacity” or “not competent,” with no decision attached, tells the next clinician nothing. Name the decision and the date and time.
A refusal of recommended care is a reason to assess, not a finding. Judge how the patient decides, not what they decide. A capable adult can make a choice you think unwise.
Pain, sedatives, low oxygen, missing hearing aids, a night-time visit, or no interpreter can make a capable patient look incapable. Fix what you can, and reassess when the decision can wait.
“Understands risks and benefits” is an opinion, not evidence. Quote what the patient said for each ability, so a reader can see how you reached the finding.
A MoCA or MMSE score describes cognition on the day, not the patient’s grasp of this decision. Record it as background, and base the finding on the four abilities.
When the patient lacks capacity, name the substitute decision-maker and what they decided, and set a time to reassess, especially when the cause, such as delirium, can clear.
Vero Scribe writes the capacity assessment in your template from the conversation, with the patient’s consent, or from your dictation, with the patient’s answers in their own words under each ability. You review and edit every section, including the conclusion, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Name the one decision and why capacity is in question. Record the information you gave, including the option of no treatment, and what you did to help the patient decide, such as treating pain or using an interpreter. Then take each of the four abilities in turn, with the patient’s own words as evidence. Give your conclusion for this decision at this time, who decides if the patient can’t, and when you will look again.
The framework most clinicians use, described by Appelbaum and Grisso, asks whether the patient can communicate a choice, understand the relevant information, appreciate how it applies to their own situation, and reason about the options. Structured tools such as the MacCAT-T are built on the same four abilities. Laws word their tests differently, so check the test where you practice.
In many places, capacity is a clinician’s judgment about one decision, and competence is a legal status that a court decides. Other places use “capacity” for both and give the clinician’s finding legal force, with a right to have it reviewed by a board or tribunal. Use the terms your law uses.
Usually the clinician proposing the treatment, since they know the decision best. Some places or decisions call for someone else as well, such as a psychiatrist, a second physician, or a designated assessor, and some, such as guardianship, go to a court. A psychiatry consult helps when mental illness may be shaping the choice, or when the finding is likely to be disputed.
No. Many people with dementia can make many decisions, especially early on. A cognitive score describes thinking on the day; it doesn’t show whether the patient understood and weighed this decision. Record the score as background, and base the finding on the four abilities.
Yes. A capable adult can refuse any treatment, even when you disagree and the refusal could shorten their life. A refusal of high-benefit care is a good reason to assess carefully, but an unwise choice isn’t proof of incapacity. Record the information given, the patient’s reasons in their words, and that they know they can change their mind.
The assessment is your clinical note, written in the chart at the time, on one treatment or care decision. A capacity letter gives your opinion to a lawyer on whether a patient could make a will or a power of attorney. Each has its own decision, legal test, and reader.
Yes. Copy it, or download it as a Word or text file. No account needed.
The clinician’s assessment after a positive screen: ideation, intent, means, the formulation, and the plan.
Falls history, gait and balance tests, orthostatic BP, medication review, and a plan matched to the risk.
The full pre-op assessment before noncardiac surgery: history, capacity, RCRI, airway, medication plan, and a clear recommendation.
System-by-system exam with normal findings written out, space for abnormal findings, and sensitive exams when indicated.
After a job offer: the job’s demands, relevant history, immunizations, vision and hearing, a job-focused exam and tests, and a fit outcome without the diagnosis.
Capacity, cognition, and care planning notes for older adults, drafted for your review.
Consult and capacity notes, drafted from the conversation.
Bedside notes in the emergency department, drafted for your review.
The consent discussion and signature, once the patient can decide.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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