Medical Decision-Making Capacity Assessment Checklist
Use this form to document a structured assessment of a person’s ability to understand, appreciate, reason about, and communicate a medical decision. The form title must remain exactly “Medical Decision-Making Capacity Assessment Checklist” everywhere it appears.
Patient and Assessment Context
Patient Name or Identifier
*
Assessor Name
*
Assessor Role / Title
*
Assessment Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Decision / Topic Being Assessed
*
Assessment Setting / Context
*
Inpatient
Outpatient
Emergency
Other
Capacity Evaluation Checklist
Understanding of medical information
*
Unable to understand
1
2
3
4
Fully understands
5
1 is Unable to understand, 5 is Fully understands
Ability to appreciate consequences
*
Unable to appreciate
1
2
3
4
Fully appreciates
5
1 is Unable to appreciate, 5 is Fully appreciates
Ability to reason about options
*
Unable to reason
1
2
3
4
Fully reasons
5
1 is Unable to reason, 5 is Fully reasons
Observed indicators by domain
*
Outcome and Documentation
Overall Capacity Determination
*
Capable
Not Capable
Needs Further Evaluation
Deferred
Rationale / Notes
Recommended Next Step / Follow-up
Please Select
No further action
Reassess after additional information
Refer for specialist evaluation
Discuss with family/supports
Implement support plan
Other
Submit
Should be Empty: