Capacity Evaluation Report Example, Template & Guide

What Is a Capacity Evaluation?

A capacity evaluation is a clinical assessment of whether an individual can make a specific decision or perform a specific task at a specific point in time — most commonly whether a patient can provide informed consent to (or refusal of) medical treatment, and increasingly whether an adult can manage finances, live independently, or execute legal documents. This guide covers civil capacity evaluation and includes both a blank template and a fully written capacity evaluation example, modeled on a hospital consultation for medical decision-making capacity.

Capacity questions sit at the intersection of clinical care, ethics, and law. Adults are presumed to have capacity; the burden falls on the evaluator to demonstrate, with specific evidence, that a particular ability is impaired for a particular decision. Because a finding of incapacity can result in a patient's stated wishes being overridden — or, in the guardianship context, in the removal of civil rights — the evaluation must be rigorous, decision-specific, and documented in functional terms a treatment team, ethics committee, or court can rely on.

Capacity evaluations are requested of psychologists, psychiatrists, and neuropsychologists across settings: hospital consultation-liaison services, memory clinics, long-term care, outpatient practice, and adult protective services investigations. The same core framework applies across these settings, adjusted for the decision at issue and the intended audience of the report.

Competency vs. Capacity: The Distinction That Frames the Report

The terms are often used interchangeably in casual speech, but the distinction matters and should be documented correctly.

Capacity is clinical. It is a professional judgment, made by a clinician, that a person can or cannot perform a specific decision-making task right now. A capacity opinion does not change anyone's legal status. It guides the treatment team — for example, whether to obtain consent from the patient or turn to an advance directive or surrogate decision-maker under the applicable state process.

Competency is legal. Only a court can adjudicate a person incompetent (many modern statutes now say the person "lacks legal capacity") and transfer decision-making authority to a guardian or conservator. Clinical capacity evaluations are frequently the central evidence in those proceedings, but the clinician's opinion is advisory — the judge decides.

The criminal context is a different question entirely. Competency to stand trial is a criminal forensic assessment governed by the Dusky standard — whether a defendant can understand the proceedings and assist counsel. A civil capacity evaluation shares the functional, present-focused logic of a competency-to-stand-trial evaluation but addresses different abilities against different standards. Do not import criminal competency language into a civil capacity report, and do not accept a referral for "a competency eval" without clarifying which question is actually being asked.

The guardianship context is the civil-legal end of the spectrum. When a capacity evaluation is prepared for a guardianship or conservatorship petition, it becomes a forensic document: notification requirements, jurisdiction-specific legal standards, and least-restrictive-alternative analysis all apply. See the companion guide to the full guardianship/conservatorship evaluation for that report structure; this page focuses on the clinical capacity assessment itself, which is the engine of both bedside consultations and guardianship evidence.

When You Need It

• When a patient refuses recommended medical treatment and the team questions whether the refusal is capacitated
• When a patient with known or suspected cognitive impairment (dementia, delirium, brain injury, intellectual disability, severe mental illness) faces a significant treatment decision
• When a patient requests discharge against medical advice and the team must determine whether the choice is capacitated
• When a hospital ethics committee or risk management requests a formal consultation on decision-making capacity
• When family members, adult protective services, or an attorney raise concerns about an adult's ability to manage finances, resist exploitation, or live safely at home
• When a capacity opinion is needed as evidence in a guardianship or conservatorship proceeding, or at the annual review of an existing guardianship
• When an attorney requests an assessment of capacity to execute a legal document (will, power of attorney, contract) — noting that these tasks have their own legal standards and, for wills, often require retrospective or contemporaneous documentation

Key Components

Referral Question and Decision at Issue

State precisely what capacity is being assessed: capacity to consent to or refuse a named treatment, capacity to manage finances, capacity to live independently, capacity to designate a power of attorney. "Global capacity" is not an assessable construct — if the referral is vague, clarify it before evaluating. Document who requested the evaluation and why now.

Notification and Consent to the Evaluation

Explain the purpose of the evaluation to the examinee in plain language, including who will receive the report. In a bedside consultation this is part of ordinary informed consent to assessment; in a guardianship context it is a formal forensic notification, including the non-confidential nature of the report. Document the person's response and apparent understanding. A person may lack capacity for the target decision yet still assent to the interview; document assent and any objections.

Sources of Information

List interview dates and durations, records reviewed (medical chart, imaging and laboratory results relevant to reversible causes, prior cognitive testing, prior capacity assessments), collateral contacts (family, treating physicians, nursing staff, case managers), and instruments administered.

Relevant History

Summarize the medical and psychiatric history bearing on the capacity question: neurocognitive diagnoses and trajectory, psychiatric conditions, current medications (especially sedatives, opioids, anticholinergics, steroids), sensory impairments, substance use, education and literacy, primary language, and baseline functioning. Identify potentially reversible contributors — delirium, depression, medication effects, metabolic disturbance, untreated hearing loss — because their presence may make incapacity temporary and reassessment mandatory.

Mental Status and Cognitive Screening

Document a current mental status examination and, where indicated, structured cognitive screening (e.g., MoCA) or referral for formal cognitive or neuropsychological testing. Report scores as context, not as the capacity determination: no screening cutoff establishes or excludes capacity by itself.

Decision-Specific Assessment: The Four Abilities

The core of a medical decision-making capacity evaluation is a structured interview organized around the four-abilities model (Appelbaum & Grisso). Structured aids such as the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) or the Aid to Capacity Evaluation (ACE) can scaffold this interview, but the four abilities can also be assessed through careful, documented clinical questioning:

Understanding. Can the person paraphrase — not merely echo — the relevant information: the nature of the condition, the proposed treatment, its risks and benefits, the alternatives, and the likely consequences of no treatment? Disclose the information first, in plain language, then ask the person to explain it back. Capacity assessment is only fair if the disclosure was adequate.

Appreciation. Does the person accept that the information applies to them? Probe beliefs about the diagnosis ("Do you believe you have this condition?") and about the treatment's potential to benefit or harm them personally. Failures of appreciation are typically driven by delusions, anosognosia, or severe denial — distinguish these from religious or cultural frameworks and from disagreement with medical opinion, which are not incapacity.

Reasoning. Can the person compare options and connect consequences to their choice? Ask them to explain how they reached their decision, what would happen with each option, and what matters most to them in choosing. The standard is a rational process consistent with the person's own values — not a "correct" conclusion.

Expressing a choice. Can the person communicate a clear decision, and is it reasonably stable across the interview (and, where possible, across days)? Frequent reversals may indicate impairment; a considered change of mind after new information does not. Accommodate communication impairments — writing, gesture, augmentative communication, interpreters — before concluding this ability is impaired.

Functional and Task-Specific Evidence

For non-medical capacities (finances, independent living), supplement the interview with functional evidence: performance-based tasks (bill-paying, making change, medication management demonstrations), collateral reports of real-world functioning, and documented incidents (missed payments, exploitation, unsafe wandering). Real-world performance evidence is often more probative than test scores.

Opinion and Recommendations

State the opinion in decision-specific terms: which abilities are intact, which are impaired, the clinical cause of any impairment, and the resulting opinion on capacity for the named decision. Address reversibility and reassessment. Where impairment exists, recommend the least restrictive path: supported decision-making, involvement of an existing health care agent or power of attorney, treatment of reversible contributors — reserving surrogate decision-making or guardianship referral for when supports are insufficient. If the report will enter a guardianship proceeding, map the findings to the functional domains the court must consider under the jurisdiction's statute.

Capacity Evaluation Example (Completed Sample Write-Up)

The following filled-in example shows the decision-specific assessment and opinion sections of a medical decision-making capacity consultation for a fictional hospitalized client. Note how each of the four abilities is documented with the client's own words and specific behavioral evidence.

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How to Complete It Step by Step

Step 1: Pin down the decision. Before scheduling the interview, convert the referral into a specific, assessable question: capacity to consent to or refuse which intervention? Capacity to manage which financial tasks? If the referral is "assess capacity" with no object, contact the referrer. The entire structure of the evaluation — the information to disclose, the abilities to probe, the functional evidence to gather — flows from the decision at issue.

Step 2: Rule the moment in or out. Check for acute, reversible conditions that would make today's assessment unrepresentative: active delirium, intoxication or withdrawal, acute pain, sedating medication just administered, missing hearing aids or glasses, no interpreter for a non-English-speaking patient. If a reversible barrier is present, treat or accommodate it first, or document that the finding may be temporary and set a reassessment plan.

Step 3: Verify the disclosure. A person cannot demonstrate understanding of information they were never adequately given. Review what the treatment team actually told the patient (and how), or make the disclosure yourself during the interview in plain language, in the person's primary language, at an appropriate literacy level. Provide it in writing when memory impairment is present — the standard is whether the person can use the information, with reasonable supports, not whether they can memorize it.

Step 4: Assess the four abilities with open-ended probes. Ask the person to teach the information back ("Tell me in your own words what the doctors say is going on"), probe appreciation ("Do you believe that applies to you? What do you think would happen to you if you decline?"), elicit reasoning ("How did you weigh it? What matters most to you here?"), and confirm a stable choice. Record the person's actual words — quotations are the most persuasive evidence in a capacity report.

Step 5: Add cognitive and functional data proportionate to the stakes. For a routine decision with a cooperative patient, a mental status exam and structured interview may suffice. For a high-stakes refusal, a contested guardianship, or suspected exploitation, add standardized screening or testing, performance-based functional tasks, and collateral interviews. Apply proportionate rigor: the graver and less reversible the consequences, the more thorough and better-documented the assessment should be.

Step 6: Integrate — and separate process from outcome. Write the opinion so that it stands on the person's demonstrated abilities, not on whether the decision is medically advisable. If you conclude capacity is lacking, specify which ability failed, with evidence, and identify the clinical cause. If you conclude capacity is intact despite a worrying choice, say so plainly and document the evidence that the four abilities are functioning.

Step 7: Address what happens next. State whether impairment is likely temporary and when to reassess. Recommend supports that could restore or scaffold decision-making (treatment of depression or delirium, communication aids, supported decision-making, involvement of trusted family). If surrogate decision-making is needed, point to the least restrictive mechanism available — an existing advance directive or health care agent before a court process, and a limited rather than plenary arrangement where a guardianship evaluation goes forward.

Common Mistakes

1. Treating a diagnosis or test score as the answer. "MoCA 21, therefore lacks capacity" and "has schizophrenia, therefore lacks capacity" are both indefensible. Diagnoses and scores establish that impairment is possible; only the decision-specific assessment establishes whether the relevant abilities are actually impaired for this decision. The example above deliberately shows intact capacity alongside a below-cutoff screening score.

2. Confusing disagreement with incapacity — in either direction. Do not question capacity only when patients refuse. A patient who passively agrees to everything may lack understanding just as profoundly, and consent from an incapacitated patient is not informed consent. Conversely, do not let a refusal you find unwise pull the opinion toward incapacity; document the reasoning process and let it speak.

3. Rendering a global verdict. "Patient lacks capacity" without an object invites the report to be misused for decisions never assessed — finances, discharge disposition, legal documents. Every capacity statement in the report should name the decision and the date, and the opinion section should say explicitly what it does not cover.

4. Assessing before disclosure, or through communication barriers. Concluding that a person "could not describe the risks of surgery" when no one clearly explained those risks — or when the person's hearing aids were in a drawer and no interpreter was called — documents the system's failure, not the patient's incapacity. Fix the disclosure and the communication supports first.

5. Mislabeling the legal posture. Writing "the patient is incompetent" in a clinical note overstates the clinician's authority; writing a guardianship report without forensic notification, jurisdiction-specific standards, and least-restrictive-alternative analysis understates the forensic obligations. Keep the vocabulary aligned with the context: clinical capacity at the bedside, legal capacity for the court — and cross-reference the competency-to-stand-trial framework only to distinguish it, never to borrow its standard.

6. Ignoring fluctuation. A single interview during a lucid interval, or during an evening confusional period, can misrepresent the person's typical functioning. When capacity may fluctuate, document the time of day, corroborate with nursing or family observations across the day, and consider a second interview before finalizing a high-stakes opinion.

Ethical Considerations

• The presumption of capacity is the starting point. Every adult is presumed capable of making their own decisions until specific evidence shows otherwise. The evaluator's job is not to protect the person from a bad decision but to determine whether the decision is theirs — made with functioning understanding, appreciation, reasoning, and choice.

• Autonomy and protection pull in opposite directions. An overly permissive assessment can leave an impaired person exposed to serious harm or exploitation; an overly protective one strips a capable person of self-determination. Managing this tension honestly — including documenting the evidence on both sides — is the core ethical discipline of capacity work.

• Cultural, religious, and linguistic humility. Decisions grounded in religious belief, cultural frameworks, or values the evaluator does not share are not evidence of impaired reasoning. Assess whether the person's decision coheres with their own long-held values (collateral history helps establish this), and use qualified interpreters rather than family members for the assessment itself.

• Dual roles and referral pressure. Treatment teams and families sometimes want a particular answer — an incapacity finding that unlocks a needed placement, or a capacity finding that relieves the team of a difficult conflict. The evaluator's opinion must rest on the assessment data. In guardianship matters, be explicit about who retained you and follow forensic-role guidance rather than treating-clinician norms.

• Document for the reader who will rely on it. A capacity report may be read by surgeons at 2 a.m., by an ethics committee, or by a judge. Quotations, specific behavioral evidence, and a clearly bounded opinion (this decision, this date, this cause, this reassessment plan) make the report usable and defensible. Conclusory language ("patient is confused and cannot decide") serves no reader.

• Preserve remaining rights. When impairment is found, recommendations should preserve every capacity the person retains: limited rather than global surrogate authority, supported decision-making where the jurisdiction recognizes it, and reassessment when reversible conditions resolve. Incapacity findings should open the narrowest possible door, for the shortest necessary time.