Short: Can understand information? Can retain the information? Can weigh up the information? Can communicate their decision? Comprehensive: Proposed treatment and/or course of action? Proposed treatment and/or course of action is the least restrictive option and represents and balanced approach to safeguarding the patient's best interests? Y/N Assessment of capacity: Patient free to make their own decision without external pressure? Y/N Has been given sufficient information, in a way they can understand, to inform them of the decision they need to make (eg appropriate language, non verbally, jargon free, etc.)? Y/N Able to communicate a decision effectively? Y/N Able to have a rational conversation about the pros and cons of what is proposed? Y/N Understanding of what is proposed and why? Y/N Understands the principle risks and benefits of what was proposed? Y/N Understands the reasonably foreseeable consequences of receiving the proposed treatment? Y/N Can retain information for long enough to make a valid decision? Y/N Is able to use and weigh this information in the decision making process? Y/N Assessment of patient's best interests: Is it likely that the patient will, at some time, have capacity in relation to the matter in questions and if so, when? Permitted and encouraged patient to participate, or to improve their ability to participate, as fully as possible, in any acts done for them and any decision affecting them, which may mean making significant reasonable adjustments around communication? Y/N Consulted with those close to the patient (eg spouse/partner, relative, carers, advocates)? Y/N Who? Good reason to believe that the patient would not have wished particular individuals to be consulted? Y/N Urgency did not prevent consultation? Y/N Good reason to believe that the patient's best interests would not be served by involving certain individuals? Y/N Agreement - based on medical/clinical considerations and including factors such as the patient's past and present wishes, feelings and beliefs when competent (and in particular any relevant written statements made when the person had capacity), other factors that the patient would be likely to consider if able to do so like general well-being, spiritual and religious welfare, and beliefs and values that would be likely to influence the patient's decision if they had capacity - that the proposed treatment and/or course of action is the least restrictive option and represented a reasonable and balanced approach to safeguard what is reasonably believed to be the patient's best interests and to the best of my and the knowledge of those close to the patient the patient has not refused the proposed treatment and/or course of action in a valid and applicable advance decision, nor was there a relevant Lasting Power of Attorney, nor was there a relevant Court Appointed Deputy? Y/N Not been able to consulting with anyone close to the patient in order to take their knowledge of the patient's views and beliefs into account in determining their best interest for the following reason? Y/N Treatment and/or course of action, is in my clinical judgement, in the best interests of the patient, who lacks capacity to consent? Y/N Reference(s): Department of Health (2019): Mental Capacity Act Forms Gov.uk (2021): Make decisions on behalf of someone NHS (2018): Mental Capacity Act NHS Southend CCG (2018): Mental Capacity Assessment Form