Free Capacity Evaluation Template
Capacity Evaluation
[YOUR COMPANY NAME]
Patient Information:
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Name |
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Age |
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Date of Evaluation |
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Evaluator |
Introduction
This form serves as a systematic approach to assess a patient's capacity for decision-making regarding health care and financial management.
Overview
This evaluation will be conducted in a comprehensive and precise methodology to ensure accurate findings. Results will contribute decisively to the patient's care and treatment plans.
Evaluation Criteria
1. Knowledge: Measures the patient's understanding of their medical condition, prospective treatment, financial responsibilities, and potential outcomes.
2. Reason: Ability to weigh the benefits and drawbacks of alternative solutions for their medical and financial management.
3. Appreciation: Assesses whether the patient comprehends the personal implications and consequences of their decisions.
4. Choice: Determines if the patient is capable of communicating their decisions clearly and consistently.
Evaluation Table
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Evaluation Criteria |
Description |
Score (1-5) |
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Knowledge |
Can the patient accurately define and understand their medical or financial situation? |
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Reason |
Does the patient adequately weigh the benefits and risks of their options? |
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Appreciation |
Can the patient comprehend the personal implications and consequences of their choices? |
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Choice |
Can the patient communicate their decisions clearly and consistently? |
Scoring: 1 (Poor), 2 (Fair), 3 (Good), 4 (Very Good), 5 (Excellent)
Additional Notes and Comments
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Comments |
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