Help the team make decisions about whether residents can do the same.
1. Ability to Process Information
3= Understands, processes and follows complex directions.
2= Understands and follows basic directions (i.e., ADL's).
1= Understands and follows one-step directions.
0= Unable to understand or follow any directions.
SCORE:
2. Ability to Recognize that Choice Exists
3= Receives information and understands relevance of choices in relation to own values and beliefs.
2= Receives information and recognizes choices exist but is unable to relate choices to one's values and beliefs.
1= Unable to distinguish which information is relevant to making choices.
0= Unable to recognize relevant information nor understands choices exist.
SCORE:
3. Memory Recall
3= Short-term and long-term memory are intact.
2= Moderately impaired: recalls time of day (i.e., am or pm), month and/or year.
1= Severely impaired: recalls 2 of the following: time of day, month and/or year.
0= Incomprehensible language.
SCORE:
4. Ability to Reason
3= Consistent ability to reason and express decision making.
2= Inconsistent ability to reason and express decision making.
1= Minimal ability to reason and express decision making.
0= Not capable of reasoning.
SCORE:
5. Understands Consequences of Decisions
3= Fully understands and expresses consequences of decisions.
2= Understands there are consequences to decisions but unable to fully define them.
1= Does not recognize there are consequences to decisions.
1= Does not recognize there are consequences to decisions.
0= Unable to understand situation or consequences.
SCORE:
TOTAL SCORE
Resident Name: _________________________________________ Resident # _______ Unit _______ Room # _______
SCORING (For decision making)
13-15 Full decision making capacity. (Resident can make all decisions independently.)
7-12 Limited decision making capacity. (Lacks ability to make one or more complex decisions independently but still possess at minimum the capability to designate a power of Attorney. Facility must determine decision making capability on a decision by decision basis. Surrogate will be involved in complex decision making.)
0-6 None. (Unable to make decisions but may express preferences, i.e., food, clothing, and daily routine.)
SIGNATURES OF ID TEAM MEMBERS
Signature and Credentials Date
_________________________________________________________________ _________________________
_________________________________________________________________ _________________________
_________________________________________________________________ _________________________
_________________________________________________________________ _________________________
_________________________________________________________________ _________________________
Comments: _______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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Resident Name: _________________________________________ Resident # _______ Unit _______ Room # _______
Source: Masonic Village at Elizabethtown
