What key information should be documented when requesting a capacity evaluation?

Key Documentation for Capacity Evaluation Requests

When requesting a capacity evaluation, document the specific decision requiring assessment, observable behaviors suggesting impaired understanding or appreciation, and the clinical context that triggered concern—not merely a diagnosis.

Essential Elements to Document

1. The Specific Decision in Question

• Clearly identify what decision needs to be made (e.g., refusing surgery, accepting treatment, discharge planning, financial decisions)
• Document the complexity and risk level of the decision, as this determines the rigor needed in evaluation 1
• Note that capacity is decision-specific—a patient may have capacity for simple decisions but not complex ones 2

2. Observable Evidence of Potential Incapacity

Document concrete observations across these domains 3:

• Cognitive concerns: Specific examples of impaired memory, reasoning, or judgment
• Behavioral changes: Observable alterations in decision-making patterns
• Functional decline: Documented difficulties with activities requiring similar cognitive demands
• Awareness deficits: Evidence of anosognosia (lack of illness awareness) or inability to appreciate consequences

3. Information from Collateral Sources

• Informant reports from family, caregivers, or others who know the patient well 3
• Changes in baseline functioning as reported by those familiar with the patient
• Discrepancies between patient's self-report and informant observations

4. Assessment of the Four Capacity Standards

Document your preliminary observations regarding whether the patient can 4:

• Understand their medical situation and the information provided
• Appreciate the situation and its consequences for themselves
• Reason with the information (manipulate and compare options)
• Express a choice that remains stable over time

5. Medical and Psychiatric Context

• Current medical conditions affecting cognition (delirium, stroke, dementia) 5
• Psychiatric diagnoses that may impair decision-making
• Medications or metabolic factors affecting mental status
• Avoid triggering evaluation based solely on diagnosis—focus on functional impairment 1

6. Risk-Benefit Context

Document 1:

• The risks of the decision being made (or refused)
• Anticipated benefits or harms
• Time sensitivity of the decision
• Whether the decision is reversible

7. Efforts to Enhance Capacity

Document all attempts made to optimize the patient's decision-making ability before requesting evaluation 3, 2:

• Simplifying information presentation
• Treating reversible causes (pain, delirium, medication effects)
• Providing written materials or visual aids
• Allowing time for questions and repeated discussions
• Involving care partners in education

8. Why the Evaluation Would Change Management

Critically important: Document how the capacity determination would alter the care plan 6

• What would happen if capacity is present vs. absent?
• Is surrogate decision-making being considered?
• Are there legal or ethical implications requiring formal assessment?

Common Pitfalls to Avoid

• Don't equate disagreement with incapacity: An "unwise" decision is not evidence of lacking capacity 2
• Don't assume capacity based on agreement: A patient who agrees with your recommendation may still lack capacity 2
• Don't request evaluation without clinical uncertainty: Assume capacity unless there is reasonable doubt 6
• Don't use diagnosis as the trigger: Focus on functional evidence of impaired decision-making, not the underlying condition 1

Documentation Framework

Structure your request to include:

1. The specific decision requiring capacity assessment
2. Observable behaviors suggesting impaired understanding/appreciation (with examples)
3. Collateral information from informants about baseline and changes
4. Your preliminary assessment of the four capacity standards
5. Medical/psychiatric factors potentially affecting cognition
6. Steps already taken to enhance capacity
7. How the evaluation will impact care (what changes based on the result)
8. Risk level and urgency of the decision

This structured approach ensures the evaluator has sufficient context to conduct a targeted, legally defensible assessment that addresses the specific clinical question 5, 4.