An Electronic Template to Support Clinical Evaluations of Decision-Making Capacity: A Feasibility Study.
Abstract
Background
Tools for decision-making capacity assessment exist but are infrequently used in clinical practice. Our institution created a capacity template embedded in the electronic health record (EHR) to assist providers with capacity assessments. Our goals were to examine the feasibility and utilization of the tool to support independent capacity assessments by non-psychiatry providers and examine the clinical aspects of this tool's utilization between psychiatry and non-psychiatry clinicians.
Methods
We tracked utilization of the template and collected user information, including department/division and training level, then performed mixed-methods analysis. We examined the number of consults to the psychiatry department for capacity before (January 2021 through December 2022) and after (January 2023 through December 2024) implementation of the template. Finally, we performed quantitative tallies and qualitative coding analysis of a purposive subsample of patient notes that utilized the tool to elucidate relevant clinical issues related to capacity evaluations.
Results
No revisions of the template were required after the development phase. Of 450 template entries over the course of two years, the highest usage was by the hospital medicine division (N=229 (50.9%)) and by residents (N=178 (39.6%)), and the most common reason for template usage was leaving Against Medical Advice (AMA) (N=182 (40.4%)). The proportion of psychiatry consultations for capacity evaluations decreased from 8.9% (N=377 out of 4221 total consultations) to 5.4% (N=187 out of 3469 total consultations) between the pre- and post-implementation periods of the template's release. Qualitative analysis of medical records for the purposive subsample (N=30) suggested that psychiatric consultations were ordered more so when admitting teams found patients did not have medical decision-making capacity than when admitting services' assessment was that the patient did have capacity.
Conclusion
Our results highlight the feasibility of a templated capacity assessment EHR tool that can assist clinicians in performing and documenting capacity assessments. This tool can be especially helpful for hospital medicine teams needing to independently complete capacity assessments, although psychiatry consultations may remain needed in complex clinical scenarios.