How do I document the mental capacity assessment to ensure compliance with legal requirements?

The mental capacity assessment should be documented at an appropriate level to the complexity of the decision being made, either as a stand-alone document or within the individual's health or social care record, and should include the timescale for review ¹.

The documentation must record the practicable steps taken to help the person make the decision, any steps taken by other parties, and whether the person has capacity to make the decision ¹.

If the person is assessed as lacking capacity, the reasons for this, the identified impairment or disturbance, and how it prevents decision-making must be clearly documented, referencing section 3 of the Mental Capacity Act 2005 ¹.

The outcome of the assessment should include any differing views on capacity and how they are addressed, and if no evidence displaces the assumption of capacity, this should be recorded ¹.

After the assessment, provide emotional support and information, acknowledging the potential for distress during the process ¹.