Mental Capacity Audit Checklist Form
Use this checklist to record observations, assess decision-making capacity, and note any follow-up actions.
Audit Subject Details
Subject name or identifier
*
Audit date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor name
*
Relationship to subject or role
*
Self
Family member
Caregiver
Clinician
Social worker
Other relevant role
Capacity Checklist Assessment
Understanding of information
*
Very limited
1
2
3
4
Excellent
5
1 is Very limited, 5 is Excellent
Ability to retain information
*
Very limited
1
2
3
4
Excellent
5
1 is Very limited, 5 is Excellent
Ability to weigh information and consequences
*
Very limited
1
2
3
4
Excellent
5
1 is Very limited, 5 is Excellent
Ability to communicate a decision
*
Consistently able
Partially able
Not able
Unable to assess
Observed indicators of capacity concerns and support needed
Audit Outcome and Notes
Overall Capacity Conclusion
*
Appears to have capacity
Capacity unclear
Further assessment recommended
Narrative Notes / Observations
Follow-up Action Required
*
Please Select
No action
Seek professional review
Repeat audit
Support plan update
Other
Submit
Should be Empty: