How to document a patient's inability to make decisions due to confusion?

Documentation of Patient's Inability to Make Decisions Due to Confusion

When documenting a patient's inability to make decisions due to confusion, you should clearly record the specific assessment of capacity, the reasons for incapacity, and the decision-making process that follows.

Assessment and Documentation of Capacity

• Document that capacity is assumed initially, as required by law, until proven otherwise through specific assessment 1
• Record evidence of the patient's impairment or disturbance in the functioning of their mind or brain that affects decision-making 1
• Document your assessment of the four key components of decision-making capacity:
  • Inability to understand relevant information about the decision 1
  • Inability to retain that information long enough to make the decision 1
  • Inability to use or weigh that information as part of the decision-making process 1
  • Inability to communicate their decision by any means 1, 2

Specific Documentation Requirements

• Include the date, time, and setting of the capacity assessment 2
• Document the specific decision(s) for which capacity is being assessed, as capacity is decision-specific 3, 2
• Record specific examples of the patient's confusion and how it impacts their ability to make the particular decision 1
• Document any attempts made to enhance the patient's capacity (timing of discussion, communication aids, simplified explanations) 1, 4
• Include verbatim quotes from the patient that demonstrate their confusion or inability to understand 2
• Document consultation with family members, friends, or other healthcare providers who can provide insight into the patient's baseline cognitive function 1

Documentation of Decision-Making Process

• Record who has been identified as the authorized surrogate decision-maker 1
• Document any advance directives, lasting power of attorney, or court-appointed deputies that were reviewed 1
• Record discussions with the surrogate about the patient's previously expressed wishes, values, and preferences 1
• Document the clinical reasoning that led to the determination that the patient lacks capacity 1, 4
• Record that decisions made on behalf of the patient are in their best interests 1

Common Pitfalls to Avoid in Documentation

• Avoid documenting that a patient lacks capacity simply because they make an unwise or unusual decision 1
• Do not document lack of capacity based solely on a patient's diagnosis, age, or appearance 1
• Avoid vague statements like "patient confused" without specific examples 2, 5
• Do not document a global assessment of incapacity; instead, specify which decisions the patient cannot make 3, 4
• Avoid documenting that capacity was assessed without describing the specific methods used 2, 4

Special Considerations

• For temporary confusion (delirium, medication effects), document plans for reassessment of capacity when the condition may improve 1
• If the patient refuses to participate in capacity assessment, document this refusal and your observations of their behavior and reasoning 6
• For emergency situations where treatment cannot be delayed, document why emergency intervention without formal consent was necessary 2
• Document any disagreements between healthcare team members or family regarding the patient's capacity and how these were resolved 1