Trust Board Febuary 2010 - Sandwell & West Birmingham Hospitals

SWBTB (2/10) 037 (b)
Appendix D
Functional Test of Capacity
Assessment of Mental Capacity
Is there an impairment of, or disturbance in, the
functioning of the person’s mind or brain (it does not
matter if this is permanent or temporary)?
yes\no
Record of decision to be made:
Does the impairment or disturbance make the person
unable to make the particular decision?
yes\no
Can the person:
yes\no
1) Understand the information relevant to that
decision?
If no please state reason:
2) Retain that information? yes\no
If no please state reason:
3) Use or weigh that information as part of the
process of making the decision?
If no please state reason:
yes\no
4) Communicate their decision (whether by
talking, using sign language or any other
means)?
If no please state reason:
yes\no
Record actions taken:
Name of member of staff……………………
Designation…………………………………..
Signature…………………………Date…………….
Ward\Department……………………………