Recording Mental Capacity Assessments Clearly

A note that says “patient lacks capacity” tells the next person almost nothing.

Capacity is decision-specific and time-specific. The record should show which decision was being considered, how the person was supported, what they said or did, and why the conclusion was reached.

Good documentation is not about filling the page with legal wording. It is about making the reasoning clear enough that another professional can understand what happened.

Start With the Exact Decision

Do not begin with a broad label such as “no capacity” or “confused”.

Write the decision that needed to be made. For example:

• capacity to consent to the proposed intravenous antibiotics
• capacity to decide whether to remain in hospital for treatment
• capacity to agree to the proposed discharge destination

A person may be able to make one of these decisions and not another. Naming the decision keeps the assessment focused.

Record Why Capacity Was in Question

The record should explain what prompted concern.

This might include new delirium, drowsiness, a brain injury, severe mental illness, intoxication, or difficulty understanding information that would normally be manageable for the person.

A diagnosis alone is not enough. “Patient has dementia” does not explain whether the person can make the particular decision today.

Describe the relevant observations without speculation. For example, record that the patient repeatedly forgot the proposed procedure within a few minutes, rather than simply writing that they were “not with it”.

Show the Support That Was Tried

In England and Wales, the Mental Capacity Act 2005 requires all practicable steps to help the person decide before treating them as unable to do so. Scottish practice also requires appropriate communication support and attention to the adult’s wishes and abilities.

The record may need to show:

• how the information was explained
• whether plain language, pictures or written information were used
• whether an interpreter or communication aid was provided
• whether hearing aids or glasses were available
• whether pain, anxiety or environmental distractions were addressed
• whether the conversation took place at the person’s best time of day
• whether a trusted person or advocate supported communication

If the assessment was delayed because the decision could safely wait until delirium or sedation improved, that should also be clear.

Record the Person’s Responses

Where possible, use the patient’s own words.

Instead of writing “unable to understand”, record what information was given, the questions used to check understanding and how the person responded.

For an assessment under the Mental Capacity Act 2005, the record should address whether the person could:

• understand the relevant information
• retain it long enough to decide
• use or weigh it as part of the decision
• communicate their decision by any means

Do not turn this into four unexplained tick boxes. The evidence matters.

For example, the person may be able to repeat that surgery is proposed but be unable to use or weigh the information about what may happen if it is refused. That distinction is more useful than a single yes or no entry.

Link the Conclusion to the Evidence

National Institute for Health and Care Excellence guidance says that when a practitioner concludes a person lacks capacity, the reasons should be clearly documented.

The conclusion should make sense when read alongside the evidence. In England and Wales, it should also show the link between the person’s inability to make the decision and an impairment of, or disturbance in, the functioning of the mind or brain.

If the person has capacity, record that conclusion clearly too. A difficult, risky or unpopular decision does not become evidence of incapacity simply because others disagree with it.

Do Not Mix UK Legal Language

The legal framework must match the place of practice.

England and Wales use the Mental Capacity Act 2005 and its best-interests framework.

Scotland uses the Adults with Incapacity (Scotland) Act 2000. The Scottish principles focus on benefit, the least restrictive option, the adult’s wishes, consultation with relevant others, and encouraging the adult to use and develop their skills.

Northern Ireland has the Mental Capacity Act (Northern Ireland) 2016, but it has been implemented in phases and is not yet fully commenced.

A template copied from another UK nation may use the wrong legal test or terminology. Follow the documentation and policy used by your organisation.

Who Was Involved?

Record relevant involvement without implying that relatives automatically make the decision.

This might include:

• the registered professional responsible for the treatment
• members of the multidisciplinary team
• family or carers who provided information about wishes and communication
• an independent advocate
• an attorney, guardian or deputy with powers relevant to the decision

The legal document and the scope of any representative’s powers should be checked. “Next of kin informed” does not establish legal authority.

Document What Happened Next

The record should not stop at the capacity conclusion.

It may need to include:

• the decision or action taken
• how the person remained involved
• the legal basis used
• the person’s known wishes, feelings, beliefs and values
• less restrictive options considered
• who was informed
• when reassessment is planned
• any disagreement and how it was escalated

If capacity may fluctuate, record the plan to review it. A conclusion made during acute illness should not quietly become a permanent label in the notes.

A Practical Example

14:10: Capacity considered in relation to consent to intravenous antibiotics for suspected infection. Patient has acute delirium documented by the medical team. Information about the infection, proposed treatment, expected benefits and material risks was explained using short sentences in a quiet side room. Hearing aids were in place. Patient’s daughter was present at the patient’s request and assisted with usual communication only.

Patient could state that an infection was suspected but was unable to retain information about the proposed treatment for more than a few minutes despite repetition and written prompts. They could not explain the likely consequences of accepting or refusing treatment. Registered nurse and responsible doctor informed. Formal decision-making and treatment plan completed by the responsible clinical team under the applicable legal framework. Patient’s views continued to be sought. Reassessment planned following treatment of delirium.

This is only an example of the level of clarity that may be useful. Real documentation must reflect what actually happened and the process used in your clinical area.

What Should a Student Nurse Write?

Students should document within their competence, level of responsibility and local rules.

You may record your direct observations, the communication support you provided, what the patient told you, who you informed and when you informed them.

Do not present yourself as having completed a formal assessment that you did not lead. Do not copy another professional’s conclusion without making clear whose assessment it was.

If your notes are reviewed or countersigned in your placement area, follow that process. Ask before writing if you are unsure.

The NMC Record-Keeping Link

The Nursing and Midwifery Council Code requires clear and accurate records to be completed at the time or as soon as possible afterwards. Records should identify risks or problems and the steps taken to deal with them.

That fits capacity documentation perfectly. The note should be timely, factual, attributable and useful to the next person caring for the patient.

The Bleepbook Takeaway

Do not only record the answer. Record how the team reached it.

Name the decision, show the support provided, describe the patient’s responses, link the conclusion to the evidence and make the next steps clear.

“Lacks capacity” is a conclusion. The documentation needs to show the reasoning underneath it.

References

Department of Health Northern Ireland. Mental Capacity Act background.

National Institute for Health and Care Excellence. Decision-making and mental capacity (NG108).

Nursing and Midwifery Council. The Code.

Scottish Government. Communication and assessing capacity.