RECORD OF MENTAL CAPACITY ASSESSMENT
Name
Start Date
NHS number
Hospital number
Draig number
Reason for this assessment
Type of decision to be made
Serious medical treatment
Change in accommodation
Care planning and review
Adult Protection measures
Major financial
Deprivation of Liberty Safeguards
X
Specify decision to be made
Other (Major decisions, not daily activity)
UA110 MCA Assessing Capacity FINAL NTB 24june 08
STAGE 1
Does the person have an impairment of, or a disturbance in the functioning of
their mind?
Impairment or nature of disturbance in mind function
Y
N
Date above was assessed
Name, title, organisation, address of diagnostician if different from assessor (incl. location of records)
Is impairment / disturbance (mark with X)
Fluctuating
Temporary
Comments:
Permanent
UA110 MCA Assessing Capacity FINAL NTB 24june 08
STAGE 2: Does the impairment or disturbance mean that the person is unable to make this
specific decision when they need to?
Date decision required by
Comments:
a. Is the person able to consent to this
assessment?
Y
N
b. Have they consented?
Y
N
c. Can the decision be delayed until recovery,
better circumstances, or until the person has
gained skills to make the decision themselves?
Y
N
Date / time and location of capacity assessment(s)
Date
Time
Location
UA110 MCA Assessing Capacity FINAL NTB 24june 08
Methods of Communication Used (Mark all that apply)
Spoken English
Spoken Welsh
Other spoken language (specify)
British Sign Language
Makaton
Braille
Written English
Written Welsh
Other written language (specify)
Pictures / Photos
Audiotape
Other (specify)
If used, name / details of interpreter or supporter assisting interview(s)
If used, name / details / date of any consultation or specialist opinion and summary of relevant
information (attach any Specialist Assessments)
List any other actions taken to enhance capacity
UA110 MCA Assessing Capacity FINAL NTB 24june 08
Determinants of capacity
1. Does the person understand relevant
information about the decision to be made?



4.
N Comment:
Y
N Comment:
Y
N Comment:
Evaluate the information
Use the information to make a decision
Decide without undue influence, persuasion or to
please others
Can the person communicate their decision
by any means?

Y
Able to retain information with memory, notebook,
photograph, poster, video, voice recorder, computer,
etc.)
3. Can the person use or weigh the information
as part of the decision making process?



N Comment:
Understand that a decision needs to be made
Understand the nature of the decision
Understand the likely consequences of the decision,
and of making no decision
2. Can the person retain that information in their
mind for long enough to make the decision?

Y
( By any means – e.g. muscle movements, blink, hand
squeeze)
UA110 MCA Assessing Capacity FINAL NTB 24june 08
Does the person have the capacity to make the
decision in question?
Y
N Comment:
If the person does not have the capacity to make
the decision in question, can they be assisted to
make some contribution towards the decision?
Y
N Comment:
Assessor/ Decision Maker details
Signature
Print Name
Job Title
Assessor’s Address
Telephone No
Date assessment completed
UA110 MCA Assessing Capacity FINAL NTB 24june 08