Yes/No Yes/No Yes/No The following interested persons have not been consulted for the following reasons NAME REASON CONNECTION TO THE PERSON BEING ASSESSED Section 1: DOCUMENTATION I have considered the following documents (e.g. current care plan, medical daily record sheets, risk assessments) DOCUMENT NAME - I have reviewed the following documents DATED Section 2: MENTAL CAPACITY ASSESSMENT The following practicable steps have been taken to enable and support the person to participate in the decision-making process: In my opinion the person LACKS capacity to decide whether or not they should be accommodated in this hospital or care home for the purpose of being given the proposed care and/or treatment, and the person is unable to make this decision because of an impairment of, or a disturbance in the functioning of, the mind or brain. In my opinion the person HAS capacity to decide whether or not they should be accommodated in this hospital or care home for the purpose of being given the proposed care and/or treatment Stage One: What is the impairment of, or disturbance in the functioning of the mind or brain?
Yes/No Yes/No Yes/No The following interested persons have not been consulted for the following reasons NAME REASON CONNECTION TO THE PERSON BEING ASSESSED Section 1: DOCUMENTATION I have considered the following documents (e.g. current care plan, medical daily record sheets, risk assessments) DOCUMENT NAME - I have reviewed the following documents DATED Section 2: MENTAL CAPACITY ASSESSMENT The following practicable steps have been taken to enable and support the person to participate in the decision-making process: In my opinion the person LACKS capacity to decide whether or not they should be accommodated in this hospital or care home for the purpose of being given the proposed care and/or treatment, and the person is unable to make this decision because of an impairment of, or a disturbance in the functioning of, the mind or brain. In my opinion the person HAS capacity to decide whether or not they should be accommodated in this hospital or care home for the purpose of being given the proposed care and/or treatment Stage One: What is the impairment of, or disturbance in the functioning of the mind or brain?