CAPACITY 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]