Assessment of Mental Capacity

**Patient Particulars** **Name (in NRIC):** [patient's full legal name] (Print the patient's full name as registered on their National Registration Identity Card, Foreign Identification Number document, or passport. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading and label, and leave blank.) **NRIC/FIN/Passport:** [patient's identification number] (Print the patient's National Registration Identity Card number, Foreign Identification Number, or passport number, matching the type of identification provided. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading and label, and leave blank.) **Date of Birth:** [patient's date of birth] (Print in DD/MM/YYYY format, where DD is the zero-padded day, MM is the zero-padded month, and YYYY is the four-digit year. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading and label, and leave blank.) **LPA Reference No:** [Lasting Power of Attorney reference number] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading and label, and leave blank.) **1. Date and Time of Assessment** [date of assessment] (Print in DD/MM/YYYY format, where DD is the zero-padded day, MM is the zero-padded month, and YYYY is the four-digit year. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading, and leave blank.) [time of assessment] (Print in 24-hour HH:MM format, where HH is the zero-padded hour and MM is the zero-padded minute. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading, and leave blank.) **2. Specific Decision Being Assessed** [specific decision under assessment] (Capture the precise decision being assessed, recognising that mental capacity is time-specific and decision-specific. The decision may relate to activation or deactivation of a Lasting Power of Attorney for personal welfare matters, activation or deactivation of a Lasting Power of Attorney for property and affairs matters, consent to a specific medical or dental treatment, a decision about where the patient lives, or any other specific decision the patient is being asked to make. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading, and leave blank.) **3. Assessment Methodology Used** Clinical background: [relevant clinical background, including diagnoses and medical history] (Summarise the patient's clinical background relevant to the mental capacity assessment, including previous diagnoses of relevant medical conditions such as dementia and any pertinent medical history. Where information from the National Electronic Health Record or previous medical records was referred to, summarise only the relevant information; do not directly reproduce information from the National Electronic Health Record, as this information may be disclosed to third parties. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) Setting and timing: [setting and timing of assessment] (Describe the setting and timing chosen to allow the patient to be assessed at their optimal cognitive state. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) Communication approach: [communication adjustments used] (Describe communication adjustments used during the assessment, such as use of simple language, allowing adequate time for the patient to process and express themselves, use of visual aids, or any other supports used to maximise the patient's ability to understand and communicate. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) Cultural or language considerations: [cultural or language factors and interpreter arrangements] (Note any cultural or language barriers identified and any impartial interpreter arrangements made. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) Third parties present: [persons present during the assessment and rationale] (List any third parties present during the assessment and the rationale for their presence. Where the assessment relates to a Lasting Power of Attorney, note whether potential donees or other parties were excluded from the room to avoid undue influence. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) Corroborative history obtained: [corroborative history obtained from caregivers] (Document corroborative history obtained from caregivers such as family members or professional caregivers from a nursing home, including who was interviewed and the key information they provided. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) Cognitive screening tool used and result: [cognitive screening tool used and result] (Print the name of the cognitive screening tool used, such as Mini-Mental State Examination or Abbreviated Mental Test, and the result obtained. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) **4. Clinical Findings** Step 1: Impairment of, or disturbance in the functioning of, the mind or brain: [findings on impairment or disturbance] (Document whether the patient has an impairment of, or a disturbance in the functioning of, the mind or brain, and describe the nature of this impairment or disturbance. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) Step 2: Functional ability to make the specific decision: (Only include this subheading if any of the four functional abilities below is mentioned in the transcript, contextual notes, or clinical note; else omit this subheading and all four ability subheadings entirely.) Ability to understand the information relevant to the decision: [observations on the patient's ability to understand] (Describe the patient's ability to understand the information relevant to the specific decision, including whether explanations were given in a way appropriate to the patient's circumstances using simple language, visual aids, or any other means. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) Ability to retain the information: [observations on the patient's ability to retain information] (Describe the patient's ability to retain the information relevant to the decision. The ability to retain information for a short period only does not prevent the patient from being regarded as able to make the decision. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) Ability to weigh options and consequences: [observations on the patient's ability to weigh options and consequences] (Describe the patient's ability to use or weigh the information as part of the process of making the decision, including consideration of the reasonably foreseeable consequences of deciding one way or another or of failing to make the decision. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) Ability to communicate the decision: [observations on the patient's ability to communicate the decision] (Describe the patient's ability to communicate the decision, whether by talking, using sign language, or any other means. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) Other clinical observations: [other relevant clinical observations made during the assessment] (Capture any other relevant clinical observations made during the assessment, such as appearance, behaviour, mood, speech, thought form and content, perception, insight, and judgment. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) **5. Reasoning for Conclusions** Clinical reasoning: [clinical reasoning linking the findings to the determination of mental capacity] (Explain the clinical reasoning that links the findings from Step 1 and Step 2 to the determination of mental capacity for the specific decision being assessed. Apply the principles under the Mental Capacity Act: the patient must be assumed to have mental capacity unless it is established that they lack mental capacity; the patient is not to be treated as unable to make a decision unless all practicable steps to help them have been taken without success; and the patient is not to be treated as unable to make a decision merely because they make an unwise decision. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) Determination of mental capacity for personal welfare matters: [determination for personal welfare matters] (Print one of "has mental capacity in respect of personal welfare matters", "lacks mental capacity in respect of personal welfare matters", or "patient to be referred to a specialist for assessment". Personal welfare matters include decisions such as where the patient lives and consent to medical and dental treatment. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) Determination of mental capacity for property and affairs matters: [determination for property and affairs matters] (Print one of "has mental capacity in respect of property and affairs matters", "lacks mental capacity in respect of property and affairs matters", or "patient to be referred to a specialist for assessment". Property and affairs matters refer to matters concerning the patient's financial affairs and property. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) Permanence of mental incapacity: [permanence assessment] (Print one of "likely to be permanent", "not likely to be permanent", or "patient to be referred to a specialist for assessment". Only include where mental incapacity has been determined and only if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) Estimated validity period of this assessment: [estimated validity period before a newer assessment should be done] (Print the estimated validity period of this assessment before a newer assessment should be done, where the mental incapacity is not likely to be permanent. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) Indication for specialist referral: [indication for specialist referral and basis] (Indicate whether referral to a specialist is required and the basis for referral. Specialist referral should be considered where there are complex medical conditions requiring expert evaluation beyond the General Practitioner's scope of professional competence, or where a conclusive assessment cannot be made. Examples of conditions or factors that may require specialist referral include cognitive impairment due to medical causes such as traumatic brain injury or cerebrovascular accident, fluctuating cognitive impairment such as delirium, early-stage dementia, or clinical depression, major or severe mental disorders such as active schizophrenia or delusional disorder, and complex circumstances such as suspected undue influence on donors. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit subheading entirely.) **6. Follow-up Plan if Needed** [follow-up plan including review intervals, referrals, repeat assessment timing, and any further investigations] (Detail the follow-up plan, including any review intervals, referrals to specialists, timing of repeat assessment, and any further investigations required. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading, and leave blank.) (Use third person clinical voice throughout. Apply Singapore English spelling and Ministry conventions, including "judgment" rather than "judgement".)