An Audit of Documentation relating to Decision-Making Capacity at an Old Age Psychiatric Hospital in England

The Mental Capacity Act 2005 (MCA) guides clinicians in England and Wales in how to support patients to make a capacitous decision. Documentation of patients’ capacity is mandatory for certain decisions in psychiatric hospitals so as to evidence the use of the MCA guidance. Given the importance of decisions such as where to live and what medication to take, the quality of clinician interview and documentation is important to monitor.Method: The quality and quantity of decision-making capacity (DMC) documentation was reviewed in a psychiatric hospital in England for older adults. The clinical records of 49 discharged patients were examined retrospectively. All DMC documentation found was compared with existing legal guidance on capacity assessment.Results: 46/58 DMC documents were found to be insufficient. There was little evidence of what information had been given to patients to enable autonomous decision making, what actions had been undertaken to optimise capacity and what alternative decision options were presented.Conclusions: Consideration should be given by hospital managers to support DMC assessment by staff. Further reflection is needed on the part of regulators regarding the optimum DMC documentation standard, particularly regarding physical health medication for psychiatric inpatients. Guidance and training for all staff involved in the assessment and documentation of DMC should be made available.