Healthcare Crisis Competency Exam

HEALTHCARE CRISIS COMPETENCY EXAM

This form documents a time-limited clinical assessment of the individual's decision-making competency during an acute crisis. It records presenting circumstances, focused mental status findings, the examiner's clinical determination regarding capacity to consent to treatment and/or to manage urgent risk, and any recommended interventions. Information documented herein will be used for clinical decision-making and relevant care planning.

1. Patient Information

2. Insurance / Coverage (if applicable)

3. Medical / Psychiatric History

4. Presenting Crisis

Date of assessment:    Time:

5. Focused Mental Status / Capacity Components

Orientation (check those that are intact):   Person Place Time

Immediate recall (number of items recalled):    Short-term recall:

Understanding of condition / treatment options: Intact Moderately impaired Severely impaired / Absent

Appreciation of consequences (ability to apply information to self): Intact Impaired Absent

Ability to communicate a consistent choice regarding care: Able to communicate choice Inconsistent Unable

Reasoning and ability to provide a rational explanation for a decision: Intact Impaired Absent

Suicidal ideation or self-harm intent Homicidal ideation or risk to others Inability to meet basic needs / self-care Acute intoxication or withdrawal

6. Capacity Determination & Clinical Rationale

Based on the clinical interview, mental status examination, collateral information, and observed behavior, the examiner's functional determination regarding the patient's capacity to make informed decisions for urgent care during this crisis (select one):

The patient is competent to understand and make informed decisions for urgent care at this time.
The patient demonstrates limited capacity; can make some decisions with supported decision-making or specific restrictions.
The patient lacks capacity to consent to urgent care decisions at this time.

7. Legal / Privacy Acknowledgment

The assessment and this record are maintained as part of the patient's health record and are subject to professional confidentiality protections. Information may be disclosed as necessary to provide care, to protect the patient or others from imminent risk, or where otherwise permitted or required by law.

I acknowledge that I received and understand the privacy information and that this assessment may be shared with treating clinicians as necessary for my care during the crisis.

Authorization to share crisis-assessment findings with identified parties for care coordination (optional):

Authorization expiration date: (If left blank, authorization expires when the crisis episode resolves or per facility policy)

8. Examiner Information (Attestation)

Date of examination:    Time:

Examiner attests that the examination documented above was performed directly by the examiner, that the findings recorded are true to the best of their professional judgment, and that the capacity determination is based on the functional abilities described herein.

9. Patient Consent / Signature

By signing below, I acknowledge that I have been informed of the assessment findings and understand the recommended interventions. I understand that I may withdraw consent for non-emergency interventions at any time and that emergency interventions may be initiated if there is an imminent risk to myself or others.

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