Requirements Specification for Mental Capacity
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| The mental capacity of the patient to make decisions about treatment etc. Example, where an Independent Mental Capacity Advocate
(IMCA) is required for decisions relating to discharge destination, medical treatment, ability to consent etc. Any information
given to a significant other in relation to this matter.
Requirement Reference: A Clinician’s Guide to Record Standards – Part 2: Standards for the structure and content of medical
records and communications when patients are admitted to hospital (Academy of Medical Royal Colleges, October 2008).
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Mental Capacity
Business DefinitionThe mental capacity of the patient to make decisions about treatment, including whether an Independent Mental Capacity Advocate
is required for decisions relating to discharge destination or ongoing treatment.
NOTE: The LRA Discharge Summary expert group 2011 questioned how this data would be consistently interpreted and also who
was expected to capture and use this data. (For example, if this is mainly about mental capacity to consent to treatment,
this would be expected to be time-specific information, relevant at the time of requesting consent, but not necessarily useful
at the time of discharge from hospital.) It was suggested that this type of data would more appropriately be included in the
Clinical Narrative summary of the hospital stay, or Problems or Issues at Discharge, along with additional clinical context.)
This requirement has been included in order to be consistent with the published Academy of Medical Royal Colleges Discharge
Summary content standard, but clarification will be requested as input to future iterations of the Academy’s professional
standard.
Requirement Reference A Clinician’s Guide to Record Standards – Part 2: Standards for the structure and content of medical records and communications
when patients are admitted to hospital (Academy of Medical Royal Colleges, October 2008).
Proposed Data ValuesFree text.
Data UseUnknown.
Data SourceUnknown.
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