Healthcare Competency Assessment

HEALTHCARE COMPETENCY ASSESSMENT

Client Name:    Date of Birth:    Medical Record / ID:

Assessment Administration

Date of Assessment:

Referral / Reason for Assessment

Please indicate reason(s) prompting this competency assessment (check all that apply):

  Admission evaluation

  Capacity to consent to medical treatment / procedures

  Capacity for consent to surgery/anesthesia

  Discharge placement planning

  Financial decision-making capacity

  Guardianship / conservatorship determination

Relevant Medical and Social History

Standardized Assessment Tools / Observations

Tests administered (check all that apply and record score where appropriate):

  MMSE (score):

  MoCA (score):

  SLUMS (score):

  Clock Drawing (notes):

Clinical Assessment: Capacity Domains

Observed or Reported Impairing Factors

  Delirium or fluctuating consciousness
  Intoxication or substance effects
  Communication impairment / aphasia
  Severe mood disorder interfering with judgment
  Progressive cognitive impairment / dementia
  Significant sensory deficits (hearing/vision)
  Language barrier requiring interpreter
  Other:

Decision-Specific Capacity Determinations

For each decision area, select the assessor's determination and provide brief justification.

Summary, Conclusion, and Recommendations

Summary conclusion (clinical judgment):

  Refer for neuropsychological evaluation

  Initiate guardianship / conservatorship process

  Designate or confirm surrogate decision-maker

  Continued inpatient monitoring for delirium or reversible causes

Authorization to Disclose Assessment Results

  Patient authorizes disclosure of assessment results to identified parties for care coordination.

Authorization expiration date:

HIPAA & Patient Rights Acknowledgment

By signing below the patient or legal representative acknowledges receipt of this assessment and understands that these clinical findings will be recorded in the medical record. The patient retains the right to request clarification, a second opinion, or to pursue legal review if a formal legal determination of competency is desired.

  I acknowledge receipt of this assessment and understand the stated rights.

Patient / Representative Contact

Assessor Attestation

I certify that I conducted the above clinical assessment using the information available at the time of evaluation, that my determination reflects my professional judgment concerning the patient's decision-specific capacity, and that I have documented test results and observations supporting this determination. This clinical assessment is not a formal legal adjudication of competency but may be used to inform legal proceedings.

Sign Now